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Dental restoration note

Tooth and surface identification, consent discussion and a record of the restoration performed.

United StatesBlank template
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Blank documentation outlines for US practice. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

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Dental restoration note

Encounter

Patient name: [ ] Date of birth: [ ] Date and time of encounter: [ ] Clinician: [ ]

Indication and preparation

Tooth number or letter using Universal notation and surfaces: [ ] Diagnosis and supporting findings: [ ] Medical history and allergy updates: [ ] Options, risks, alternatives and patient consent: [ ]

Procedure performed

Local anesthetic agent, concentration, amount and route if used: [ ] Isolation and preparation: [ ] Findings during treatment: [ ] Restorative materials, shade and product details: [ ] Contacts, occlusion and finishing actually checked: [ ] Complications and response: [ ]

Aftercare

Post-treatment findings and patient response: [ ] Instructions discussed: [ ] Follow-up plan: [ ]