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Every dental procedure performed in the chair is documented as a Clinical Procedure record. Whether it is a simple filling or a complex crown placement, the procedure record captures what was done, on which tooth, with which materials, and links to the billing item for invoicing.

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Before You Start

  • Clinical Procedure Templates must be set up for each procedure type before they can be ordered from a Patient Encounter.
  • Procedure templates include the billing item and duration so that the system can invoice correctly.
  • You need the Healthcare Practitioner role to create and submit procedure records.

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Setting Up Clinical Procedure Templates

Create a procedure template for each type of dental treatment your clinic offers.
  1. Go to Healthcare workspace → Consultation Setup card → Clinical Procedure Template → New
Clinical Procedure Template form showing procedure name, medical department, billing item, duration, consumable items section, and rate
Recommended Dental Procedure Templates:

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Documenting a Dental Procedure

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Method 1: From the Patient Encounter

While in the Patient Encounter, go to the Orders section and add a Clinical Procedure order. This creates the procedure record linked to the encounter.

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Method 2: From the Clinical Procedure List

  1. Go to Healthcare workspace → Consultation card → Clinical Procedure → New
  2. Link to the patient and the encounter manually

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Completing a Clinical Procedure Record

After the procedure is performed:
  1. Open the Clinical Procedure record (linked from the encounter or from the procedure list)
  2. Set the Status to “In Progress” as you begin, then “Completed” when done
  3. Complete the procedure details:
  1. Add tooth-specific details in the Notes field:
    • Tooth number (FDI notation preferred: e.g., tooth 16, 46)
    • Surface (e.g., MO, DO, MOD, buccal, composite to incisal edge)
    • Material used (e.g., nanofill composite shade A2, GIC Type II)
    • Anaesthetic given (e.g., Lignocaine 2% with 1:80,000 adrenaline, 1 cartridge, inferior alveolar block)
    • Post-procedure instructions (e.g., avoid hot drinks for 1 hour, no biting on hard food for 24 hours)
  2. Submit the Clinical Procedure record.
After submission:
  • The procedure appears in the patient’s history timeline
  • The procedure’s billing item becomes available for invoicing
  • The “Appointments to Bill” count reflects the unbilled procedure
Completed Clinical Procedure record for a composite filling showing tooth 36, surfaces MOD, material used, anaesthetic given, and status as Completed

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Common Procedure Documentation Details

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Scaling and Polishing

Notes to record:
  • BPE scores before and after (if reassessment performed)
  • Calculus location (supragingival, subgingival, generalised/localised)
  • Areas of special attention
  • Oral hygiene instruction given (brushing technique, interdental cleaning, mouthwash recommendation)
  • Planned recall interval (3 months, 6 months, 12 months)

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Composite Filling

Notes to record:
  • Tooth number and surface(s)
  • Caries removed (extent: enamel only, into dentine, approaching pulp)
  • Cavity liner placed (e.g., Dycal, GIC base)
  • Composite shade selected
  • Bonding system used
  • Bite check and adjustment
  • Post-operative sensitivity warnings given

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Root Canal Treatment

Notes to record:
  • Tooth number and root(s)
  • Pre-treatment radiograph (IOPA taken and attached)
  • Access cavity preparation: bur type, rubber dam used (yes/no)
  • Working length determination: apex locator and/or radiograph, working length in mm for each root
  • Canal preparation: hand files or rotary, final apical size
  • Irrigation protocol (NaOCl concentration, EDTA, final flush)
  • Obturation: technique (lateral condensation, warm vertical), material (gutta-percha + sealer)
  • Post-obturation radiograph (IOPA taken and attached)
  • Temporary or permanent seal placed
  • Treatment session: visit 1 of X, or single visit

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Crown Preparation

Notes to record:
  • Tooth number and type of crown (metal-ceramic, full zirconia, EMAX, gold)
  • Occlusal and axial reduction achieved
  • Margin type (shoulder, chamfer, feather edge) and location (supra/sub-gingival)
  • Impression material and technique (alginate, silicone, digital scan)
  • Shade recorded (using shade guide system)
  • Temporary crown placed (material, cemented with temporary cement)
  • Shade and shape requirements communicated to laboratory
  • Expected laboratory return date

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Denture Impression

Notes to record:
  • Dentition type (complete upper, complete lower, partial upper, partial lower)
  • Special tray or stock tray
  • Impression material
  • Shade and mould selected for teeth
  • Post-dam and special tray modifications for complete dentures
  • Patient’s existing denture sent to lab for reference (if applicable)

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Dental Procedure Consumable Tracking

The consumables section of the procedure template and procedure record allows you to track materials used: Consumable tracking feeds into stock reports and helps with supply ordering.

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Field Guide: Clinical Procedure

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Best Practices

  • Record the tooth number in FDI notation (international standard: 11-18, 21-28, 31-38, 41-48) rather than referring to “upper right back tooth” - clear tooth number notation is essential for records, lab orders, and medico-legal purposes
  • Always document what anaesthetic was given (type, dose, technique) - this is required in dental records and has medico-legal implications
  • For multi-visit treatments (root canal spread over 2 appointments), create a procedure record for each visit and link them both to the same patient - do not wait until the final appointment to document the first visit’s work
  • Submit procedure records on the day of treatment - do not leave them in draft status, as this blocks billing and makes the patient history inaccurate
  • For crown and bridge procedures, note the lab return date in the procedure notes so the front desk knows when to book the fit appointment

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Troubleshooting

The billing item is not auto-filling on the procedure Check that the Clinical Procedure Template has a billing item linked. Open the template and add the item, then re-link the template to the procedure record. The procedure is not appearing in the patient’s history timeline Check that the procedure record has been submitted, not just saved. Only submitted records appear in the history timeline. The consumable item is coming out of the wrong stock location Check the default warehouse set on the Clinical Procedure Template. The consumable items are issued from this warehouse when the procedure is submitted.