Oral surgery

Sample note:
Extraction

Simple extraction of #3 with socket care and post-op instructions. Transcript on the left, the note as it appears in CareNotes on the right.

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General dentist, non-surgical extraction. EXT was selected before recording. Names, dates, and identifying details are fictional.

What was said

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

Dentist: So we're taking out the upper right first molar today, number three. It's broken down below the gumline and not restorable. We went over the options, including an implant down the road.

Patient: Yeah, let's just get it out. I'm not on blood thinners or anything. I'm an ICU nurse, I know the drill.

Dentist: Then you'll be my easiest patient today.

Dentist: It's out. All three roots are intact. Socket is clear, no root tips, no opening into the sinus. Bite on this gauze and hold it for thirty minutes.

Dentist: No spitting, no straws, no smoking for three days. Soft food today. Ibuprofen six hundred every six hours if you need it. If pain gets worse around day three or four, call us. Written instructions are in the bag.

What CareNotes wrote

The note before the clinician's edits, as it looks on the phone. Scroll the screen; tap a capsule to change it.

Elena V.

Side Note:
Works as an ICU nurse.
Pt CC:
EXT #3, non-restorable
RMH:
NSC. No anticoagulants.
All risks, complications, alternatives, and benefits discussed, all questions answered.
Exam:
#3 fractured subgingivally, non-restorable. Options reviewed: EXT with future implant, bridge, or no replacement. Delivered intact with all 3 roots. Socket clear, no retained root tips, no oroantral communication.
Tx:
Tooth #[3] extracted under [Lidocaine 2% 1x 1:100K epi] [Local infiltration]. Site debrided; [No graft placed]. [No suture] placed. Post-op instructions reviewed. [] Gauze for 30 minutes. No spitting, straws, or smoking for 72 hours. Soft diet today. Ibuprofen 600 mg every 6 hours as needed. Call if pain worsens on day 3 to 4.
NV:
Post-op check 1 week. Implant consult when healed.

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