Mesio-palatal composite placement UL1, with local anaesthetic (LA) via labial infiltration
Example current succinct clinical record without SOPs
Medical history checked and updated. Discussed treatment procedure (record any further discussion with patient if any queries relate to the procedure).
Patient happy to proceed, verbal consent attained.
LA 1ml (name of LA) administered via labial infiltration, labial sulcus UL1.
Isolation, caries removed mesial UL1 – palatal access, cavity prepared, etch and bond (materials used), composite MP (materials used and shade) placed and finished, occlusion checked.
Post-operative instructions given, including risks. (Insert any additional information).
Example current succinct clinical record with SOPs
Pre-op SOP number (record any further discussion with patient).
LA SOP number. 1ml (name of LA) labial infiltration, labial sulcus UL1.
SOP 5 – UL1, Composite (MP), (shade) – (insert any additional information).
Replacement PFM crown preparation at UL1, using standard local anaesthetic (LA) (1.5ml) via buccal infiltration
Example current succinct clinical record without SOPs
Appointment 1
Medical history checked and updated. Discussed treatment procedure (record any further discussion with patient if any queries relate to the procedure).
Patient happy to proceed, verbal consent attained.
Pre-operative silicone index made.
LA 1.5ml (name of LA) administered via labial infiltration, labial sulcus UL1.
Crown removed at UL1, caries removed, and composite resin core placed.
Retraction cord applied.
Upper PVS and lower alginate impressions taken.
Provisional crown made (name of material) cemented with (name of cement).
Occlusion checked, post-operative instructions given.
Shade, A2, lab prescription completed.
Example current succinct clinical record with SOPs
Appointment 1
Medical history reviewed, consent attained.
Any additional information – record as free text.
UL1, PFM replacement, SOP LA – 1.5ml (insert LA name).
SOP 10 (composite core, upper PVS and lower alginate impression and PVS bite).
Shade A2, SOP provisional crown (material for temp crown and temp cement).
Example current succinct clinical record without SOPs
Appointment 2
Medical history reviewed. No concerns reported, Consent attained.
LA 1.5ml (name of LA) administered via labial infiltration, labial sulcus UL1.
Provisional crown removed UL1, preparation cleaned.
Definitive crown tried-in, margins, contacts, appearance and occlusion checked. Patient shown crown; happy to proceed.
Crown cemented (insert cement name), excess cement removed, and occlusion and contacts checked with dental floss.
Post-operative instructions given, including risk of POS and pulp tissue complications.
Example current succinct clinical record with SOPs
Appointment 2
Medical history reviewed, consent attained.
Any additional information – record as free text.
SOP local anaesthetic – 1.5ml (insert local anaesthetic name).
UL1 PFM crown, SOP 10 (insert cement name).
Publication reference: PRN02432v