Endodontic Follow-Up Note (Post-Op/Healing Evaluation)

Date: [date of visit]

Patient: [full name, DOB]

Clinician: [clinician name and credentials]

Tooth/Procedure: [tooth number; procedure type; date performed; time since procedure; current restoration status]

Referring/Restorative Dentist: [name] (Include only if relevant to the case; otherwise omit this line.)

Interval History

Reason for visit: [patient-stated reason in their words]

Pain: [location, intensity, triggers, trend] (If denies pain, state explicitly.)

Swelling/drainage/systemic symptoms: [presence or explicit denial of each]

Function: [chewing ability, avoidance behaviors]

Interim events: [restorations placed, temporary issues, health history changes since procedure] (Omit if none.)

Examination

(Document only clinically indicated findings. If a relevant test was not performed, note reason. Use comparative terms when helpful.)

Extraoral: [relevant findings] (Include only if pertinent; otherwise omit.)

Soft tissues: [gingival/mucosal status adjacent to treated tooth; sinus tract presence/absence]

Tooth [number]: [percussion response; palpation tenderness; mobility if abnormal; restoration integrity and occlusion] (Repeat for each tooth being followed.)

Radiographic findings: [imaging type and date; comparison study; periapical status; obturation/restoration appearance] (If no imaging obtained or reviewed, state that and omit further detail.)

Assessment

(Support healing determination with brief synthesis of symptoms, clinical signs, and radiographic findings. If radiographs unavailable, note assessment is clinical-only.)

Tooth [number]: [Healed / Healing / Persistent disease suspected / Uncertain] — [brief rationale synthesizing findings] (Repeat for each tooth.)

Prognosis: [Favorable / Guarded / Poor] — [brief rationale] (Include only when it affects decision-making.)

Plan

(Document only actions taken or explicitly planned. Omit elements that do not apply.)

Procedures/medications today: [occlusal adjustment, suture removal, prescriptions with drug/dose/quantity, other interventions]

Patient instructions: [home care guidance; return precautions/red flags]

Restorative coordination: [recommendation for definitive restoration; urgency; communication to restorative dentist; patient counseling if declining/delaying]

Follow-up: [interval; radiographic intent] (Include contingency plans if healing uncertain or complications possible.)