Dental Note Examples: Narrative & SOAP | OraCore AI

Dental note examples

See what a complete dental note can look like.

Explore full clinical notes across general dentistry, hygiene and specialty care. Switch between Narrative and SOAP, then review the visit-specific benchmarks for a clinically complete note.

Read complete notes and review the benchmarks for each visit.

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Comprehensive exam + imaging

General dentistry

Reason for Visit: Patient presented for a comprehensive new-patient examination with full-mouth radiographs.

Medical History: Medical history, medications and allergies were reviewed with the patient. No contraindications to today’s examination or diagnostic imaging were identified.

Dental History: Wisdom teeth were extracted approximately 2017–2018. Patient previously completed orthodontic treatment and has a mandibular lingual retainer. A maxillary anterior tooth has received repeated composite repairs. No sensitivity was reported involving that tooth.

Imaging and Hard-Tissue Findings: Full-mouth and panoramic radiographs were obtained and reviewed with AI-assisted analysis. Probable interproximal caries was identified at #30, with a possible upper-right premolar lesion requiring clinical correlation. Existing restorations were noted. Bone levels appeared adequate radiographically, pending final clinical assessment.

Periodontal Findings: Oral hygiene was fair. Generalized supragingival calculus was concentrated along the mandibular anterior lingual surfaces and interproximal areas. Probing depths, gingival condition and bleeding assessment were pending.

Assessment: Suspected interproximal caries at #30; possible upper-right premolar caries pending clinical confirmation; generalized calculus accumulation; existing restorations.

Treatment Discussion: Radiographic findings were reviewed. The provider will determine restoration versus crown for #30 after clinical evaluation. Cleaning type will be selected after periodontal probing.

Completed Today: Comprehensive oral evaluation (D0150), full-mouth radiographic series (D0210), panoramic image (D0350), intraoral photographs and AI-assisted radiographic analysis.

Oral Hygiene Instructions: Patient currently uses disposable floss picks and a manual interproximal cleaner beneath the mandibular lingual retainer. Daily brushing, interdental cleaning and water-flosser use were reviewed.

Next Steps: Complete periodontal probing and clinical examination; determine prophylaxis type; schedule restorative care for #30 if caries is confirmed.

Clinical compliance review

Benchmarks & Evidence

OraCore identifies the appointment type, including specialty visits, and dynamically checks the note against the documentation expected for that encounter. The benchmarks turn clinical compliance review into a clear checklist: see what is present, what needs attention, and the transcript evidence behind each result.

Reason for Visit

MET

Patient presented for a comprehensive new-patient examination with full-mouth radiographs.

95%
Evidence confirmed in transcript

Medical & Dental History

MET

Medical history, medications and allergies were reviewed with the patient. No contraindications to today’s examination or diagnostic imaging were identified. Wisdom teeth were extracted approximately 2017–2018. Patient previously completed orthodontic treatment and has a mandibular lingual retainer. A maxillary anterior tooth has received repeated composite repairs. No sensitivity was reported involving that tooth.

90%
Evidence confirmed in transcript

Imaging

MET

Full-mouth and panoramic radiographs were obtained and reviewed with AI-assisted analysis. Probable interproximal caries was identified at #30, with a possible upper-right premolar lesion requiring clinical correlation. Existing restorations were noted. Bone levels appeared adequate radiographically, pending final clinical assessment.

92%
Evidence confirmed in transcript

Periodontal Findings

MET

Oral hygiene was fair. Generalized supragingival calculus was concentrated along the mandibular anterior lingual surfaces and interproximal areas. Probing depths, gingival condition and bleeding assessment were pending.

82%
Evidence confirmed in transcript

Diagnosis

MET

Suspected interproximal caries at #30; possible upper-right premolar caries pending clinical confirmation; generalized calculus accumulation; existing restorations.

84%
Evidence confirmed in transcript

Procedures Performed

MET

Comprehensive oral evaluation (D0150), full-mouth radiographic series (D0210), panoramic image (D0350), intraoral photographs and AI-assisted radiographic analysis.

94%
Evidence confirmed in transcript

Follow-Up Plan

MET

Complete periodontal probing and clinical examination; determine prophylaxis type; schedule restorative care for #30 if caries is confirmed.

91%
Evidence confirmed in transcript

Bleeding on Probing

NOT MET

Bleeding on probing was expected for this visit type but was not documented in the appointment.

0%
Expected detail not found in transcript

Simple human review

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Automatic saving

Your edits save as you work, so they stay with the note during review.

These examples demonstrate possible note outputs. The provider reviews every note before use, and each practice can customize its Note Template.

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One dynamic Note Template

One standard. Every visit. No template library.

Set how your notes should read once. OraCore applies that standard to the appointment type and visit details, while protected clinical rules help keep required documentation in place.

Simple to manageCompliance-minded controlsClinical safeguards protected
OraCore baseline

The required structure stays protected.

Clinical safeguards and supported visit types provide the starting point.

Practice settings

One shared standard.

Use the same Note Template for a solo practice, one location, or an authorized DSO practice or location.

Provider settings

Only the differences.

A provider can change their own settings. Everything else continues to follow the practice.

What you can shape

  • Note formatNarrative or SOAP
  • SectionsInclude the right information and set the level of detail
  • Writing preferencesHeadings, terminology and instructions in your practice style
  • Preview before usingSee the note in OraCore’s real note format
  • Version historyGo back when needed without managing multiple templates
Required sections and clinical safeguards cannot be accidentally removed.
How the result can lookBold inline headings

Reason for Visit: Patient presents for periodontal maintenance and upper-left scaling and root planing.

Clinical Findings: Localized bleeding, inflammation and tenderness noted in the upper-left quadrant.

Treatment: Upper-left scaling and root planing completed with local anesthesia. Fluoride varnish applied.

Home Care: Warm salt-water rinses and gentle brushing were reviewed.

Follow-Up: Return in 6 weeks for periodontal reassessment and recall determination.

The appointment type supplies the clinical structure. Your settings shape how it reads.

One current standard. Prior versions stay in History for recovery, not daily selection.
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