Orthodontic Diagnostic Records Note

Date/Time: [Date and time of encounter]

Location: [Clinic/site name]

Author: [Name, credentials]

Reason for Records: [initial records / progress records / pre-surgical / retention check / transfer case / aligner refinement / other]

Records Source: [acquired today / received from outside provider]

Pre-Acquisition Verification

(Include this section only when records are acquired today; omit entirely if records were received from an outside provider.)

• Patient identity verification: [Verification method and result]
• Medical alerts affecting imaging/positioning: [Relevant conditions such as syncope risk, mobility limitations, gag reflex, airway considerations, or "none identified"] (Include only if relevant to today's acquisition.)
• Dental alerts affecting record adequacy: [Loose teeth, recent extractions, bonded appliances, or "none identified"] (Include only if relevant.)
• Pregnancy status inquiry: [asked / answered / declined] – [Patient response or reason declined] (Include only if ionizing radiation planned. Do not infer; document actual response.)
• Imaging consent status: [Consent on file verified (date) / Consent obtained today / Unable to verify consent on file — corrective action: [action taken]] (If consent cannot be verified, document corrective action rather than proceeding.)

Diagnostic Records Acquired

(For each modality, document: obtained today; reviewed from prior records with source and date; or not obtained with reason. Never leave a modality undocumented.)

Clinical Photographs

Status: [Obtained today / Reviewed prior from [source], [date] / Not obtained: [not indicated / declined / deferred / prior acceptable]]

• Photo set type: [extraoral / intraoral / both]
• Standard views captured:
  • Extraoral: [frontal at rest / frontal smile / profile] (Note any missing views with reason.)
  • Intraoral: [frontal in MIP / right buccal / left buccal / maxillary occlusal / mandibular occlusal] (Note any missing views with reason.)
• Acquisition method: [Camera/equipment used]
• Deviations from standard set: [Description with reason, or "none"]

Adequacy: [Photos diagnostic quality adequate / Limitations: [describe] — retake [needed / not needed]]

Intraoral Scan / Study Models

Status: [Obtained today / Reviewed prior from [source], [date] / Not obtained: [not indicated / declined / deferred / prior acceptable]]

Modality: [digital scan / physical impressions / existing study models reviewed]

• (For digital scans) Arches scanned: [maxillary / mandibular / both]; Bite registration: [captured / not captured]; Completeness: [second molars captured / not captured]; Artifacts/limitations: [stitching errors / voids / soft tissue interference / none]
• (For physical impressions/casts) Impression material: [material]; Bite registration: [captured / not captured]; Cast status: [poured / pending / received]; Occlusal position: [MIP / CR]

Adequacy: [Scan/models complete and diagnostic / Limitations: [describe] — rescan [needed / not needed]]

Radiographs

(Document each image type obtained or reviewed. Provide case-specific indication for each; avoid "routine" language. Note reuse of prior acceptable images.)

• Panoramic: [Obtained today / Reviewed prior from [source], [date] / Not obtained: [reason]]
  Indication: [Clinical reason]
  Technical notes: [Positioning, motion, artifacts, or "acceptable quality"]
  Interpretation: [Preliminary review performed / Interpretation pending]
• Lateral cephalometric: [Obtained today / Reviewed prior from [source], [date] / Not obtained: [reason]]
  Indication: [Clinical reason]
  Technical notes: [Positioning, motion, artifacts, or "acceptable quality"]
  Interpretation: [Preliminary review performed / Interpretation pending]
• PA cephalometric: [Obtained today / Reviewed prior from [source], [date] / Not obtained: [reason]]
  Indication: [Clinical reason]
  Technical notes: [Positioning, motion, artifacts, or "acceptable quality"]
  Interpretation: [Preliminary review performed / Interpretation pending]
• Bitewings: [Obtained today / Reviewed prior from [source], [date] / Not obtained: [reason]]
  Indication: [Clinical reason]
  Technical notes: [Collimation, overlap, motion, or "acceptable quality"]
  Interpretation: [Preliminary review performed / Interpretation pending]
• Periapicals: [Obtained today / Reviewed prior from [source], [date] / Not obtained: [reason]]
  Teeth/regions: [Specify]
  Indication: [Clinical reason]
  Technical notes: [Cone cut, elongation, foreshortening, or "acceptable quality"]
  Interpretation: [Preliminary review performed / Interpretation pending]
• CBCT: [Obtained today / Reviewed prior from [source], [date] / Not obtained: [reason]]
  Field of view: [small / medium / large] – [region of interest]
  Indication: [Clinical reason justifying 3D over 2D imaging]
  Technical notes: [Motion, beam hardening, metal artifact, or "acceptable quality"]
  Interpretation: [Orthodontist to interpret / Oral radiologist read requested]
  Incidental findings protocol: [Plan for identification and communication]

(Omit any radiograph type not obtained and not indicated. Include only types that were obtained, reviewed, or specifically deferred/declined.)

Radiation safety: [Technique optimized per ALARA; shielding per applicable policy: [used / not used / not applicable]]

Radiographs adequacy: [Adequate for diagnostic needs / Limited by [describe] — repeat [indicated / not indicated]]

Immediate Findings

(Include only if clinically meaningful findings identified during acquisition; otherwise omit this section entirely.)

• Clinical finding: [Description] — Impact: [Clinical relevance] — Action: [Action taken]
• Incidental imaging finding: [Description] — Disposition: [Discussed with patient / Referral placed / Radiology read requested]
• Technical issue: [Patient tolerance, equipment failure, other] — Action: [Mitigation or plan]

Patient Communication

(Include only if patient had questions, concerns, or declined indicated records; otherwise omit.)

[Purpose of records explained. Patient questions addressed regarding [topic]. Declined records: [record type] declined after counseling on risks/benefits; alternative plan: [describe].]

Next Steps

• Diagnostic summary: To be completed by [Provider name] after [radiograph review / scan analysis / record compilation]. Timeline: [estimated completion]
• Treatment conference: [Scheduled for [date/timeframe] / To be scheduled within [timeframe]]
• Outstanding items: [Missing records to obtain / Radiology interpretation pending / Referral clearances needed / Restorative clearance required / None]

Attachments

(If EHR auto-links media, use brief statement; otherwise list identifiers.)

[Images saved to chart] or:

• Photo set: [Date, storage ID]
• Scan/models: [Scan or cast ID]
• Radiographs: [Study/accession ID]

Authentication

Documented by: [Name, credentials, role] — [Date/time]

Clinical reviewer: [Orthodontist name, credentials] — [Date/time] (Include only if records captured by assistant require orthodontist attestation.)