Dental Charting Checklist: Exam Findings & Treatment Needs
Ensure accurate patient records and optimal treatment planning with our Dental Charting Checklist. Streamline exam findings, track treatment needs, and boost your dental practice's efficiency - all in one place!
This Template was installed 2 times.
Patient Demographics & Medical History
Verify patient information, review medical history updates, and note any pertinent allergies or medications.
Patient Full Name
Date of Birth
Patient Age
Patient Phone Number
Medical History (Please describe)
Allergies
Primary Insurance
Current Medications (List all medications and dosages)
Extraoral Examination
Document observations of the face, lymph nodes, temporomandibular joints (TMJs), and occlusal relationships.
Patient Name
Facial Symmetry Observations
TMJ Crepitus (0-3)
TMJ Opening (Normal/Restricted/Painful)
Lymph Node Palpation (Bilateral/Unilateral/Absent)
Lymph Node Description (if palpable)
Occlusion at Rest (Class I/Class II/Class III)
Intraoral Soft Tissue Examination
Record findings regarding the lips, tongue, cheeks, palate, floor of the mouth, and oropharynx. Note any lesions, inflammation, or abnormalities.
Lips: Description of Color, Texture, and Presence of Lesions
Tongue: Description of Color, Texture, Size, and Presence of Ulcerations or Swelling
Buccal Mucosa (Cheeks): Description of Color, Texture, and Presence of Lesions
Palate (Hard & Soft): Description of Color, Texture, and Presence of Exostoses or Lesions
Floor of Mouth: Description of Color, Texture, and Presence of Swelling or Lesions
Oropharynx: Description of Tonsils, Uvula, and Posterior Pharyngeal Wall
Saliva Production
Hard Tissue Examination (Teeth)
Assess each tooth for caries, restorations, fractures, mobility, and periodontal condition. Document existing restorations and their condition.
Caries Risk Assessment (0-5)
Tooth #18 - Condition
Tooth #30 - Condition
Tooth #11 - Probing Depth (mm)
Tooth #31 - Probing Depth (mm)
Existing Restorations (Check all that apply)
Notes on Tooth #19
Periodontal Assessment
Record probing depths, recession, bleeding on probing, furcation involvement, and plaque/calculus indices.
Probing Depth (Tooth #1)
Recession (Tooth #1)
Bleeding on Probing (BOP)
Furcation Involvement (Tooth #3)
Gingival Index Score
Plaque Index Score
Additional Periodontal Notes
Radiographic Findings
Document observations from radiographs (bitewings, periapicals, panoramic). Note any pathology or areas of concern.
Radiographic Interpretation Summary
Bitewing Index (Carson Index or similar)
Presence of Pathology (check all that apply)
Specific Findings (e.g., calculus amount, bone loss)
Panoramic Radiograph Interpretation (if applicable)
Attach Radiographic Image (optional)
Occlusion & Bite Analysis
Assess the relationship of the upper and lower teeth. Note any discrepancies or issues with the bite.
Occlusal Intercuspal Position (ICP)
TMJ Status (Right)
TMJ Status (Left)
Overbite (mm)
Overjet (mm)
Detailed Occlusal Notes
Treatment Plan Recommendations
Outline proposed treatment options for identified dental needs. Prioritize treatment based on urgency and patient goals.
Detailed Treatment Plan Description
Prioritization Level
Estimated Treatment Cost
Proposed Treatment Start Date
Treatment Provider
Patient Financial Arrangement Notes
Patient Communication & Consent
Record discussion with the patient regarding findings and treatment plan. Document patient understanding and consent for proposed treatment.
Summary of Findings Discussed
Explanation of Proposed Treatment Plan
Estimated Treatment Cost
Patient Understanding of Risks & Benefits?
Consent for Specific Procedures?
Date of Next Appointment (if scheduled)
Patient Signature
Dental Management Solution Screen Recording
See how ChecklistGuro can streamline your dental practice! This screen recording showcases key features like patient scheduling, charting, billing, and insurance claim processing using our BPM platform. Perfect for dental practices looking for a simplified and efficient workflow. #DentalSoftware #DentalPractice #PracticeManagement #DentalManagement #ChecklistGuro #BPM #ScreenRecording #DentalBilling
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