Patient Dental Chart & Ongoing Care Record
This is the practice’s standing record for this patient. Clinicians and the front desk both keep it current — it is updated in place after every appointment and is never re-filled from scratch. Anything time-limited (a single consent, a one-off estimate) belongs in its own document; what lives here is the picture of the mouth and the care around it.
Section 1 — Patient Identification
Patient reference / chart number:
Registered with the practice since:
Emergency contact (name, relationship, phone):
Section 2 — Medical Alerts & Allergies
Reviewed and confirmed with the patient at every recall. Tick every flag that is currently active.
Detail of every flag ticked above, including severity and the reaction seen:
Medical history last reviewed:
Section 3 — Current Medications
One line per medicine, with dose and prescriber. Strike through and date anything that stops rather than deleting it.
Section 4 — Periodontal Status
Screening / BPE recorded on:
Bleeding on probing, mobility, recession and other periodontal notes:
Section 5 — Tooth-by-Tooth Status
One row per tooth that carries a restoration, a diagnosis or planned work. Sound, untreated teeth need no row. Add rows as the mouth changes.
Section 6 — Radiograph History
Every image taken, with the justification recorded at the time. Check this list before exposing any new film.
Attach radiographs, referral letters, lab prescriptions and clinical photographs here:
Section 7 — Ongoing Treatment Plan
The live plan, in the order we intend to work through it. Mark each item off as it is completed rather than removing it.
Plan rationale, options discussed and anything the patient has declined:
Section 8 — Hygiene & Recall
Examination recall interval (months):
Hygiene recall interval (months):
Last hygiene appointment:
Oral-hygiene instruction given, risk factors (smoking, diet, grinding) and home-care products advised:
Section 9 — Treatment & Notes Log
One dated entry per appointment — presenting complaint, what was found, what was done, materials and batch where relevant, anaesthetic used, advice given and what happens next. Append; never overwrite an earlier entry.
Correspondence, consent copies and lab documents relating to the entries above:
This chart is a clinical record. Keep it current at every appointment and retain it for the period required by your local regulator.