Headings
Chief complaint · Medical history · Site assessment · Radiographs and imaging · Bone and soft tissue · Options discussed · Risks discussed · Treatment plan
When to use it
Use this when a patient asks about replacing a missing tooth and you are assessing whether an implant fits. It documents the site, the imaging, every option offered and the risks you named, which is the record you need before surgery. It stops at the plan, so the placement itself gets its own procedure note.
Example
Fictional example
Chief complaint
Missing #19, extracted 8 months ago. Wants a fixed replacement.
Medical history
Healthy. Nonsmoker. No bisphosphonate use.
Site assessment
11 mm mesiodistal space. Adequate interocclusal room. Adjacent teeth unrestored.
Radiographs and imaging
Cone beam CT: ridge width 6.5 mm, 14 mm of bone above the canal.
Bone and soft tissue
Bone adequate. 2 mm of keratinized tissue on the buccal.
Options discussed
Implant and crown, three-unit bridge, removable partial denture, or no treatment.
Risks discussed
Nerve injury, infection, failure to integrate, possible need for grafting.
Treatment plan
Guided implant placement #19. Crown after 3 to 4 months. Written estimate given.