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Templates, Clinical notes, Dental

Dental procedure note template

A dental procedure note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated . Written by our clinical team, generic by design, with no dosing advice.

01Procedure note

TemplateDental

Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]

Dental procedure note, composite restoration

1Indication

  • The tooth, the surfaces involved and the diagnosis.

2Consent

  • How consent was taken, and the risks, benefits and alternatives discussed.
  • Whether written consent is on the record, with its date.

3Procedure

  • Anaesthesia, isolation, materials and shade, with batch numbers where recorded.

4Findings

  • The finished restoration and the occlusion checked.

5Complications

  • Any complication, or a record that there were none.
  • Anything that did not go to plan, and what was done about it.

6Aftercare and follow-up

  • Aftercare advice given, verbally and in writing.
  • Follow-up arranged, and what should prompt the patient to get in touch sooner.

Draft

[Clinician name]

[Role], [registration number]

Signed [date], [time]

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01Procedure note

SignedAI-assisted, edited by the clinician

Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person

Dental procedure note

1Indication

  • LL6 distal caries, as diagnosed. Restoration planned.00:40

2Consent

Completed by the clinician from the record.

3Procedure

  • Local anaesthetic given. Isolation achieved. Composite placed, shade recorded.02:30

4Findings

  • Restoration complete. Occlusion checked and adjusted.09:00

5Complications

Completed by the clinician from the record.

6Aftercare and follow-up

  • Advised of short-term sensitivity. Recall in six months.09:40

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

Questions

What goes in a dental procedure note?

Indication, Consent, Procedure, Findings, Complications and Aftercare and follow-up. Each section on this page lists what belongs in it, written for dental.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

The procedure note in other specialties

All clinical notes
  1. Private GPPrivate GP procedure note
  2. DermatologyDermatology procedure note
  3. AestheticsAesthetics procedure note
  4. FertilityFertility procedure note
  5. PhysiotherapyPhysiotherapy procedure note
  6. Mental healthMental health procedure note
  7. Longevity medicineLongevity medicine procedure note

Further reading

  1. ProductThe AI medical scribe for clinics
  2. Read nextWho signs an AI clinical note, and how to review it
  3. Read nextSOAP and specialty note templates for an AI scribe
  4. RegulatorThe CQC compliance hub

Come back to the note, written and ready to sign.

See the wai scribe write a dental procedure note on your own structure, in a 15 minute video call.

Request a demoEmail us