Dental notes that write themselves.

RESTORATION COMPOSITE LR6 Distal-Occlusal
Reason for Restoration: Caries  
Medical History: Checked, no changes, see attached sheet  
Consent to start tx: Verbal  

Risks: Informed patient about the uncertainty of treatment outcomes. Extensive caries involving pulp may lead to root canal treatment or extraction incurring additional costs. Less extensive caries will be restored with close monitoring for post-op symptoms (sensitivity). Advised on possible future need for cuspal coverage.  
Noted risks associated with composite restoration: Discolouration, marginal staining, chipping and fracture, post-op sensitivity.

ProcedureLocal Anaesthetic: ID block and buccal infiltration with lidocaine hydrochloride 2% 1:80000, Total Amount 2.2ml  
- Occlusion checked before starting.
- Articulating paper used to check static and dynamic occlusion.  
- Rubber dam placed.  
- Enamel-dentine junction cleared.  
- Caries in dentine removed with rosehead until hard and scratchy to probe.  
- Unsupported enamel removed  
- Contact points cleared.  
- Matrix band used, burnished against adjacent tooth, wooden wedge used.  
- Etch 20 secs, wash 20 secs, bond and air thinned LC 20 secs.  
- Restored with composite shade A2 in increments and LC 20 seconds each increment.  
- Checked contact points by flossing through – nice tight click with floss  
- Occlusion rechecked.  
- Checked for overhangs. Flush against tooth surface.  
- Post-op instructions given regarding restoration and local anaesthetic.
- Patient given an opportunity to ask questions.
- Patient happy.