Orthodontic Progress Note (Periodic Treatment Visit)

Date: [Date of visit]

Provider: [Provider name and credentials]

Location: [Clinic/site]

Subjective

(Use brief, specific entries. Include a direct patient quote only if it clarifies the chief concern. Describe reported behaviors without judgment when adherence is limited.)

• Reason for visit: [Scheduled adjustment / Problem-focused visit] — [Chief concern or request]
• Medical history update: [No changes reported / Changes noted] — [Relevant details if any]
• Symptoms since last visit: [None / Soreness / Soft tissue irritation / TMJ symptoms / Other] — [Location, severity, duration if present]
• Compliance: [Elastics / Aligners / Appliance wear] — [Hours/day or schedule] — [Reported deviations if any]
• Oral hygiene (patient-reported): [Brief routine or concerns]

Objective

(Document clinician observations that justify today's adjustments and identify complications.)

• Oral hygiene/gingival status: [Excellent / Good / Fair / Poor] — [Localized exceptions if any]
• Appliance integrity: [Appliances intact / Issues present] — [Component and tooth numbers if applicable]
• Decalcification/white spot lesions: [None observed / Present at specific teeth and surfaces]
• Orthodontic progress: [Alignment status, overjet/overbite, midlines, space closure, molar/canine relationship as relevant to current treatment phase]
• Imaging obtained today: [None / Photos / Panoramic / Cephalometric / Other] — [Key findings if any]

Assessment

(Provide concise clinical interpretation: state whether progress is on track and note limiting factors.)

• Overall progress: [On track / Behind schedule] — [1–2 sentence rationale including limiting factors if any]
• Active problems: [List problems in order of clinical importance, or "None"] (Omit this line if no active problems.)

Procedures Performed Today

(Be explicit and reproducible. State what was removed, placed, and activated using consistent tooth notation. Include only items that apply to this visit.)

• Archwires: [Arch] — Removed [wire spec]; Placed [wire spec] — [Activation details if any]
• Auxiliaries: [Power chain / Coil spring / Ligatures / Other] — [Arch and tooth range] — [Force/size if applicable]
• Elastics Rx: [Type/size/force] — [Configuration from-to] — [Wear schedule]; patient understanding confirmed
• Repairs/Rebonds: [Component] at [Tooth number] — [Procedure performed]
• IPR: [Teeth/contacts] — [Amount in mm] — [Method] — [Polish/fluoride if applied]
• Other adjustments: [Details of additional modifications]

(If no procedures were performed, replace the list above with: "No active adjustment performed—monitoring only: [Reason]")

Plan

• Return interval: [Number of weeks]
• Next visit objectives: [Planned procedures or goals]
• Return sooner if: [Specific triggers for earlier visit]
• Compliance goals: [Measurable targets for elastics/aligners/appliance wear if indicated]
• Patient education provided: [Topic — instructions given] (Include only if significant education was provided this visit.)