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 of a non-restorable molar. Procedure type set to EXT. 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: 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. Topical, then two carpules of articaine buccal and palatal. Let's give that a minute.

Dentist: Elevating with a straight elevator, buccal and mesial. It's loosening. Upper forceps, buccal palatal, rotating slightly. And it's out. Roots are intact, all three. Let me check the socket, no root tips, curetting the socket, there was some granulation tissue, irrigating.

Dentist: No sinus communication, I checked. Bone's good. Gauze, bite down firm. Hold that for thirty minutes.

Dentist: No spitting, no straws, no smoking for three days. Soft food today. Ibuprofen six hundred every six hours as needed. If you get a bad taste or pain that gets worse on day three or four, call us, that could be a dry socket. Written instructions are in the bag.

What CareNotes wrote

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

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.
Tx:
Topical. 2 carpules 4% articaine 1:100K epi buccal + palatal infiltration. Luxated with straight elevator B and M. Delivered with maxillary molar forceps, B-P pressure with slight rotation. Tooth intact, all 3 roots. Socket inspected, no retained root tips. Granulation tissue curetted, irrigated with sterile saline. No oroantral communication. Hemostasis with pressure, gauze placed. POI verbal + written: gauze 30 min, no spitting/straws/smoking 72 hrs, soft diet today, ibuprofen 600 mg q6h PRN. Dry socket and infection signs reviewed, call if pain worsens day 3 to 4. Tooth #3 extracted under Articaine 4% 2x 1:100K epi Buccal infiltration, Palatal infiltration. Site debrided; No graft placed. No suture placed. Post-op instructions reviewed.
NV:
Post-op check 1 week. Implant consult when healed.
Dr. Rivera

How the pills work

Procedure type was set to EXT before recording, so the Tx section ends with the built-in EXT sentence. Each bracketed value is a pill: the value heard in the recording fills it, and tapping it opens the full option list (tooth number, anesthetic, technique, materials). A pill with a star is this doctor's saved default; starring a choice in the picker makes it the starting value next time the same procedure is selected. An empty dashed pill, like Rx here, is a blank the doctor can fill or leave. The words around the pills are editable prose.

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.

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