When to use this exam template
Use it for new patients (D0150), comprehensive periodontal evaluations (D0180), and established patients coming back after a long absence. The comprehensive exam is the baseline every later note is compared against. If it's thin, every treatment decision that follows is harder to justify.
What to capture at a comprehensive exam
- Medical history, medications, allergies, and vitals where your office takes them.
- Extraoral, TMJ, soft tissue, and oral cancer screening findings, normal or not.
- Periodontal charting and a stated periodontal diagnosis.
- Hard tissue: existing restorations, caries, missing teeth, and occlusion.
- Radiographs taken or received, and what they showed.
- Risk assessment and a phased treatment plan, with the patient's response.
Example comprehensive exam note
New patient seen for a comprehensive oral evaluation (D0150). Reason: new to the area. Last dental visit 1–3 years ago. Conditions: hypertension. Medications: lisinopril 10mg. NKDA. BP 128/82. Extraoral WNL, TMJ WNL, soft tissue WNL; oral cancer screening performed, no abnormalities. Full-mouth 6-point charting: localized 4–5mm pockets with bleeding. Diagnosis: gingivitis. Defective restoration #30, caries #3 MO. Panoramic and bitewings taken. Caries risk moderate. Treatment plan: restorative, then preventive maintenance. Presented and accepted. Next visit: prophylaxis.
For more on structuring the plan itself, see writing treatment planning notes.