Direct Restoration Procedure Note (Filling)

Date: [Encounter date]

Provider: [Name and credentials]

Procedure: Direct Restoration

Tooth Notation: [Universal / FDI]

Procedure Summary: [One-line summary listing each restoration with tooth numbers, surfaces, and materials]

Indication and Diagnosis

(Use one entry per tooth treated. Keep descriptions objective based on clinical and radiographic findings.)

• [Tooth number], [surfaces]: [Diagnosis] — [Lesion depth if relevant] — [Symptoms if present]

Pre-Procedure Review

(Include if relevant; omit for straightforward cases where history is unchanged and diagnostics are documented elsewhere.)

• Medical considerations: [Relevant medical history impacting care]
• Radiographs reviewed: [Type and date] — [Brief interpretation relevant to planned restoration]
• Pertinent clinical findings: [Findings relevant to the restoration]

Consent

[Consent documentation] (Document that informed consent was obtained, risks discussed including postoperative sensitivity, restoration failure, recurrent caries, possible pulpitis requiring future endodontic therapy, and need for eventual replacement. Note alternatives discussed. State that questions were answered and patient agreed. If patient declined recommended care, document informed refusal with counseling provided.)

Anesthesia

Type: [None / Topical only / Local anesthesia]

(If local anesthesia was used, include the following. If no anesthesia was used, explicitly state "None" or "Topical only." Do not infer anesthesia based solely on procedure performed.)

• Agent and concentration: [Agent and concentration]
• Dose: [Number of cartridges or volume]
• Technique and site: [Injection technique and anatomic site]
• Tolerance: [Patient tolerance and any adverse reactions]

Isolation

Method: [Rubber dam / Isolite / Cotton rolls with dry angles / Other]

Contamination events: [Description and corrective steps taken / None]

Procedure Details

(Repeat the following subsection for each tooth restored during this visit.)

Tooth [Number] — [Surfaces] — [Restoration class/type]

Existing restoration removal: [Material removed and reason with notable findings / Not applicable]

Caries removal approach: [Selective removal to soft dentin / Selective removal to firm dentin / Non-selective removal to hard dentin] (State approach explicitly. If carious dentin near pulp was intentionally left, document clearly to prevent misinterpretation as incomplete treatment.)

Lesion depth: [Shallow / Moderate / Deep / Approximating pulp]

Pulp status: [No exposure / Mechanical exposure with hemostasis achieved / Carious exposure] — [Management details if applicable]

Liner/base: [Material and location / Not indicated]

Matrix/contact management: [Matrix type and technique] (Include for Class II and III restorations; omit if not applicable.)

Adhesive approach: [Total-etch / Self-etch / Selective enamel etch] (Include for bonded restorations.)

Restorative material: [Material type] — [Shade if esthetically relevant]

Placement technique: [Incremental / Bulk-fill] (Include if clinically relevant.)

Finishing: [Contouring, finishing, and polishing completed]

Verification: [Contacts checked] — [Occlusion checked and adjustments made] — [Margins verified] — [Post-op radiograph findings if taken] (Only document checks actually performed.)

Complications: [None / Problem–action–outcome description]

Post-Procedure Status

[Patient tolerance] — [Hemostasis status if relevant] — [Confirmation of restoration completion]

Post-Op Instructions

[Instructions provided] (Note topics covered: anesthesia precautions, expected sensitivity, hygiene guidance, dietary restrictions, return precautions. Indicate if written handout provided.)

Medications

(Include only if medications were prescribed or recommended.)

• [Medication name] — [Dose and directions] — [Quantity] — [Indication]

Follow-Up

(Include when applicable; omit for routine cases with standard recall.)

[Recall interval or scheduled follow-up with purpose]