Diagnostic

Sample note:
Comprehensive exam

New patient comprehensive exam with FMX, findings by tooth, and a phased treatment plan. Transcript on the left, the note as it appears in CareNotes on the right.

New patient. Dentist narrates findings aloud while charting; the assistant is at the keyboard. No built-in procedure type. Names, dates, and identifying details are fictional; the encounter is a composite written for illustration.

What was said

Excerpt. Speech-to-text ran on the phone; this text is all that left the device.

Dentist: Welcome. What brings you in, anything bothering you?

Patient: Mostly just overdue. The lower right back tooth catches food sometimes, and I'd like my front teeth whiter eventually, my sister's wedding is in the spring.

Dentist: Got it, we can plan around that. Medical history: you noted asthma, albuterol as needed, no other meds, penicillin allergy, rash. Last dental visit about three years ago.

Dentist: Full series of x-rays today. Oral cancer screening normal, lymph nodes normal, TMJ, open and close for me, no clicking, fine. Bite is class one, mild crowding lower front.

Dentist: Charting. Existing: amalgams on two, fifteen, nineteen. Crown on thirty, that's a PFM, margins look okay. Missing one, sixteen, seventeen, thirty-two, wisdom teeth. Number three, occlusal decay, into dentin on the x-ray. Thirty, open contact on the mesial, that's your food trap, and there's recurrent decay at the mesial margin of the crown. Fourteen, old amalgam with a fractured marginal ridge.

Dentist: Perio: generalized two to three, a few fours on the upper molars, bleeding localized. Moderate calculus lower front. Stage one, grade A, we'll confirm with the hygienist.

Dentist: So plan: first a cleaning with the hygienist. Then the filling on three, replace fourteen with a composite, and thirty needs a new crown because of the decay under the margin. Whitening after that if you still want it. Any questions?

Patient: How long is all that?

Dentist: Three or four visits. We'll give you the written plan and costs at the front.

What CareNotes wrote

The generated note in the CareNotes note viewer, before the clinician's edits and signature. It is interactive.

Sophie M.

Side Note:
Sister's wedding in the spring, wants whitening before then.
Pt CC:
Overdue for care. Food impaction LR posterior. Interested in whitening.
RMH:
Asthma, albuterol PRN. Allergy: penicillin (rash). No other meds. Last dental visit ~3 yrs ago.
All risks, complications, alternatives, and benefits discussed, all questions answered.
Exam:
FMX taken and reviewed. Lymph nodes WNL. TMJ WNL, no clicking or deviation. OCS negative, soft tissues WNL. Class I, mild mandibular anterior crowding. Missing #1, #16, #17, #32. Existing: #2 O amalgam, #15 O amalgam, #19 MO amalgam, #30 PFM crown. #3 occlusal caries into dentin, radiographic and clinical. #14 amalgam with fractured marginal ridge. #30 open M contact with food impaction, recurrent caries at M crown margin. Perio: generalized 2 to 3 mm, localized 4 mm maxillary molars, localized BOP, moderate calculus mandibular anterior lingual. Provisional Stage I Grade A, confirm at hygiene. Dx: caries #3, recurrent caries #30, failing restoration #14, localized mild periodontitis (provisional).
Tx:
Tx plan presented. Phase 1: adult prophy + perio charting (hygiene). Phase 2: #3 O composite, #14 composite replacing fractured amalgam, #30 crown replacement. Phase 3: elective whitening. Est 3 to 4 visits. Written plan and fees provided, pt to review. Questions answered.
NV:
Hygiene visit. Recall 6 months pending hygiene assessment.
Dr. Rivera

How the pills work

No procedure type was selected for this visit, so the Tx section is the AI's narrative alone. When a built-in procedure is selected, CareNotes adds a one-line structured sentence with tappable choices; see the composite, root canal, or extraction sample.

How it lands in the chart

On the free tier the clinician copies this note from the app or carenotes.ai/notes and pastes it into the patient's chart in any practice management system. On Premium the same note is uploaded into the chart in Open Dental, Dentrix Ascend, Eaglesoft, or Curve after the clinician taps Ready to Upload. Headings, order, and wording follow the office's own template; the Progress Note template above is the default.

What to look for

Tooth numbers and surfaces are carried from speech into the note. Anesthetic, carpule count, and technique are written out. Materials and shades are named. The medical history review, consent line, post-operative instructions, and next visit are present even when they were said in passing. Personal details the patient mentioned go to Side Note so the doctor remembers them next time. Anything not said is not invented; if a dose or a step is missing from the recording, the clinician adds it on review.

Record one visit and compare

Core notes are free with no cap. Use your own template or start with the default.