2. What a colleague needs to read

The spine of a visit

• Who was present (including interpreter or chaperone)
• Reason for attendance and relevant history
• Examination findings that change the plan (not a novel, not a blank)
• Investigations and why (or why not)
• Diagnosis or working diagnosis
• Options discussed, including doing nothing, and what the patient chose
• Treatment provided, materials, tooth notation, local anaesthetic if used
• Advice, safety-netting, and the next step

Medical history

Update it. Allergies, anticoagulants, pregnancy, and new cardiac or cancer treatment change dentistry. A tick from 2019 is not an update. Say who confirmed it.

Notation

Use a consistent tooth notation the practice has agreed. Ambiguous “upper left 6” without a system is how the wrong tooth is planned. Radiographs: why taken, what was seen, who reported.

Telephone and remote advice

A parent calling about a swollen face is a clinical contact. Date, time, who spoke, advice given, and when to attend. Do not leave it on a sticky note on the monitor.

Language

Factual, professional, no jokes about the patient. The patient may read it. “Difficult” is not a finding; “declined bite-wings after explanation of caries risk” is.