Headings
Diagnosis summary · Options presented · Sequence and phasing · Fees discussed · Questions raised · Patient decision · Consent · Next steps
When to use it
Use this when you sit down with a patient to review a multi-step plan and they decide what to do. It records the options, phasing, fees and questions, along with the choice they made and what they consented to. That makes it the record to check if a patient later says they were never told about an option or a cost.
Example
Fictional example
Diagnosis summary
Moderate periodontitis. Failing bridge #28 to #30 with recurrent decay under #28.
Options presented
New bridge, implant at #29 with crowns on #28 and #30, or removable partial denture.
Sequence and phasing
Phase 1 scaling and root planing. Phase 2 re-evaluate at 6 weeks. Phase 3 restorative.
Fees discussed
Estimate reviewed by phase. Insurance pre-authorization pending.
Questions raised
Asked to do the bridge first. Explained gums must be stable before new restorations.
Patient decision
Chose new bridge.
Consent
Signed for phase 1.
Next steps
Book two scaling visits. Submit pre-authorization.