Extraction Procedure Note (Simple/Surgical)

Date/Time of Procedure: [Date] [Start time]–[End time] (Include start and end times when sedation beyond local anesthesia is used; single timestamp acceptable for local anesthesia only.)

Location: [Clinic / OR / Office-based surgery suite]

Operator: [Primary surgeon/dentist name]

Assistant(s): [Name(s) / None]

Anesthesia Provider: [Name / Same as operator / Not applicable]

Procedure Summary

• Pre-procedure diagnosis/indication: [Diagnosis/indication]
• Post-procedure diagnosis: [Diagnosis]
• Procedure(s) performed:
  • Simple extraction(s): [Tooth number(s) and site(s) / None]
  • Surgical extraction(s): [Tooth number(s) and site(s) / None]
• Anesthesia type: [Local only / Local + nitrous / Moderate sedation / Deep sedation / General anesthesia]
• Estimated blood loss: [Minimal / Quantified amount]
• Specimens: [List with destination / None]
• Complications: [List / None]
• Disposition: [Home / Recovery / Admit] — [Stable / Condition description]

Indications and Pre-Procedure Assessment

[Brief rationale for extraction timing and indication, including relevant symptom context such as duration, swelling, drainage, or systemic symptoms when present]

• Allergies: [Allergies list / NKDA] (Emphasize anesthetics, antibiotics, analgesics, latex.)
• Relevant medications: [List] (Include anticoagulants/antiplatelets, bisphosphonates, chronic opioids/benzodiazepines.)
• Bleeding risk/plan: [Recent INR and management plan / Coordination with prescriber / Not applicable]
• Relevant comorbidities: [Diabetes / Immunosuppression / Cardiovascular disease / Other / None]
• Baseline vitals: BP [value] | HR [value] | SpO2 [value] (Include when sedation used or clinically indicated.)
• Imaging reviewed: [Type, date] — [Key findings relevant to root morphology, nerve/sinus proximity, periapical pathology] (If not obtained, document reason.)

Consent

[Informed consent discussion documented] (Include: diagnosis, proposed procedure, expected benefits, material risks tailored to tooth/site—bleeding, infection, pain, dry socket, retained root tip, adjacent tooth damage, sinus communication for maxillary posterior, nerve injury/paresthesia for mandibular molars, jaw fracture for high-risk cases—alternatives including no treatment and endodontic options when relevant, that questions were answered, and patient/guardian agreement. Note capacity determination, decision-maker identity, and interpreter use if applicable.)

[Anesthesia consent] (Include only if sedation/general anesthesia used: sedation level, key risks including respiratory depression and aspiration, NPO status confirmed, responsible adult escort arranged.)

Safety Verification

• [Pre-procedure verification completed: correct patient, correct procedure, correct tooth numbers/site, allergies confirmed, imaging available]
• [Time-out performed immediately before invasive portion]
• [Site confirmation method: tooth number read-back / diagram / radiograph displayed]

Anesthesia

Local Anesthesia

• Agent/concentration: [Agent] [Concentration] with [Vasoconstrictor / No vasoconstrictor]
• Route/site: [IAN block / PSA block / Infiltration / PDL injection / Other]
• Total dose: [Total mL or carpules] (mg/kg calculation when required)
• Topical anesthetic: [Agent / None]
• Adverse reactions: [None / Description]

Sedation/General Anesthesia

(Include only when sedation beyond local anesthesia is used.)

• Sedation level/route: [Minimal / Moderate / Deep / General] via [Enteral / Parenteral / Inhalation]
• Drugs administered: [Drug — dose — route — time] (List each agent.)
• Monitoring: [SpO2, BP/HR, RR, capnography/EtCO2 as applicable]
• Start/stop times: [Start time]–[Stop time]
• Anesthesia record: [See separate record / Not applicable]

Procedure Details

(Create a separate subsection for each extracted tooth.)

Tooth #[Number] — [Simple Extraction / Surgical Extraction]

• Approach/complexity: [Technique description] (For simple extractions, explicitly state no flap elevation, bone removal, or sectioning performed. For surgical extractions, explicitly document which maneuvers were performed and why.)
• Incision and flap: [Incision type/location, flap elevation details] (Surgical only.)
• Bone removal: [Location — method — extent] (Surgical only.)
• Tooth sectioning: [Crown vs roots — segments — rationale] (Surgical only.)
• Tooth delivery: [Elevation/luxation method, forceps, root tip management if applicable]
• Socket management: [Curettage/irrigation/granulation removal, alveoloplasty, inspection for sinus communication or nerve exposure]
• Adjuncts: [Hemostatic agent type/site — bone graft/membrane if used] (If applicable.)
• Closure: [Suture material/size/technique/number — resorbable vs nonresorbable — drain if placed]

Hemostasis: [Methods: gauze pressure / sutures / hemostatic agents / cautery] — [Endpoint: bleeding controlled / stable clot / no active hemorrhage]

Findings

(Include only if clinically significant findings present.)

• [Purulence / Cystic lining / Fractured crown or root / Ankylosis / Hypercementosis / Anatomic structure proximity / Periodontal defects / Other]

Specimens

[Specimen type — source site/tooth — destination — labeling confirmed] (State "None" if local policy requires explicit documentation; otherwise omit section.)

Complications

Complications: [None] (Always include this section. If complications occurred: describe event, immediate management, patient notification, follow-up plan, and referrals/consults obtained.)

Post-Procedure

• Immediate condition: [Patient tolerance — bleeding status — mental status if sedation used]
• Discharge after sedation: [Discharge criteria met — time — responsible adult escort present] (Include only if sedation used.)
• Post-operative instructions: [Verbal and written instructions provided and understood] (Document domains covered: bleeding control, pain management, swelling, diet, oral hygiene, activity restrictions, tobacco/alcohol avoidance, warning signs, sinus precautions if relevant, anticoagulant restart if coordinated.)
• Medications administered in-office: [Drug — dose — route — time]
• Prescriptions provided: [Drug — dose — quantity — directions — refills] (Document indication if antibiotics prescribed.)
• Follow-up: [Routine timeframe / PRN] — [Suture removal timing if nonresorbable] — [Planned additional care]

(For critical elements—tooth identification, consent, anesthesia, operative maneuvers including flap/bone/sectioning, complications, post-op instructions—use explicit "Not documented" placeholder if information unavailable. Do not infer these elements. For non-critical elements, prefer omission over placeholders.)