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Extraction note template
For a simple or surgical extraction: the tooth, anaesthetic, technique and haemostasis, plus the options discussed for replacing the space afterwards. Includes the extra consent points an extraction needs beyond the procedure itself.
PRESENTING COMPLAINT
Planned Treatment:
Assisted by:
MEDICAL HISTORY
Medical History:
Allergies:
Medications:
PMS Updated:
OPTIONS, RISKS & CONSENT
Options Discussed:
Replacement Options:
Implications Advised:
Estimate Discussed:
Risks and benefits discussed:
Verbal consent after discussion of treatment:
TREATMENT
Tooth / Teeth:
Radiograph:
Radiograph Status:
Local Anaesthetic:
Technique:
Outcome:
Haemostasis:
Haemostasis Method:
Sutures:
Suture Type:
Justification:
POST-OPERATIVE
Post-op Instructions:
Medication Dispensed / Prescribed:
Adverse Reactions / Complications:
Review:
GDC standard 4.1 expects a patient's clinical record to be made as the appointment happens, and to be accurate and complete.
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