A dental procedure note template that sets out what belongs in each section, ready to adapt to your own clinic.
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.
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
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.
