Free template
Periodontal and hygiene note template
For a periodontal assessment or hygiene visit: BPE and pocket charting, a periodontal diagnosis, and the debridement and prevention carried out. It suits a first perio assessment and a review visit alike.
PRESENTING COMPLAINT
Reason for Visit:
Assisted by:
MEDICAL HISTORY
Medical History:
Allergies:
Medications:
PMS Updated:
SOCIAL HISTORY
Smoking:
Cigarettes per Day:
Years of Smoking:
Previous Cigarettes per Day:
Previous Years of Smoking:
Vaping:
Vaping Details:
Alcohol:
Stress:
PERIODONTAL ASSESSMENT
BPE:
Oral Hygiene:
Pocket Charting:
Plaque / Bleeding Scores:
Mobility / Furcation:
Radiographs / Bone Levels:
Diagnosis:
OPTIONS, RISKS & CONSENT
Options Discussed:
Estimate Discussed:
Risks and benefits discussed:
Verbal consent after discussion of treatment:
TREATMENT & PREVENTION
Treatment:
Treatment Method:
Prevention:
Review:
GDC standard 4.1 expects a patient's clinical record to be made as the appointment happens, and to be accurate and complete.
How Assist helps
Assist fills this in for you.
Assist records the appointment and drafts a note in this structure for the dentist to review and sign off. It writes up what was said in the room, and you check every line before it goes in the record.
28 days free. No card required.