DENTAL TREATMENT PLANNING CHECKLIST: SEQUENCING & DOCUMENTATION

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--- PATIENT HISTORY & CHIEF COMPLAINT ---
[ ] Chief Complaint
[ ] Medical History
[ ] Medications
[ ] Allergies
[ ] Previous Dental Work (Crown, Bridge, Implant, Root Canal, Orthodontics, None)
[ ] Last Dental Visit

--- CLINICAL EXAM FINDINGS ---
[ ] Blood Pressure (Systolic)
[ ] Blood Pressure (Diastolic)
[ ] Overall Periodontal Health (Excellent, Good, Fair, Poor)
[ ] Plaque Index Score
[ ] Gingival Index Score
[ ] Detailed Notes on Caries Risk Assessment
[ ] Existing Restorations (Amalgam, Composite, Gold, Ceramic, None)
[ ] Any Unusual Findings or Concerns?

--- DIAGNOSTIC RECORDS ---
[ ] Panoramic Radiograph Date
[ ] Bitewing Radiograph Date
[ ] Cone Beam CT (CBCT) Date (if applicable)
[ ] Panoramic Radiograph Image
[ ] Bitewing Radiograph Images
[ ] Cone Beam CT (CBCT) Images (if applicable)
[ ] Radiographic Review Completed? (Yes, No)

--- TREATMENT OPTIONS PRESENTATION ---
[ ] Detailed Explanation of Option 1
[ ] Estimated Cost of Option 1
[ ] Pros of Option 1
[ ] Cons of Option 1
[ ] Detailed Explanation of Option 2
[ ] Estimated Cost of Option 2
[ ] Patient's Preferred Option (Option 1, Option 2, Other (Please Specify))
[ ] Patientâ€™s Questions/Concerns

--- PATIENT CONSENT & TREATMENT PLAN ---
[ ] Detailed Treatment Plan Explanation (Provided to Patient)
[ ] Patient Acknowledges Understanding of Treatment Risks & Benefits (Yes, No)
[ ] Estimated Total Treatment Cost
[ ] Financial Agreement Type (Cash, Insurance, Payment Plan)
[ ] Date of Consent
[ ] Patient Signature
[ ] Doctor Signature

--- PHASE BREAKDOWN & SEQUENCING ---
[ ] Phase 1 Start Date (Sequence)
[ ] Phase 1 Treatment Type (Periodontal Scaling & Root Planing, Restorative - Small Classifications, Endodontic - Single Tooth, Other (Specify))
[ ] Estimated Phase 1 Completion Date
[ ] Approximate Phase 1 Cost
[ ] Phase 2 Treatment Type (Restorative - Larger Classifications, Implant Placement, Prosthodontics, Orthodontics, Other (Specify))
[ ] Sequence Rationale (Briefly explain order of phases)

--- FINANCIAL ARRANGEMENTS & INSURANCE ---
[ ] Patient's Estimated Total Cost
[ ] Insurance Provider (Delta Dental, Cigna, Aetna, Blue Cross Blue Shield, Other)
[ ] Insurance Claim Submission Date
[ ] Patient's Co-Pay Amount
[ ] Financial Agreement Signed? (Yes, No)
[ ] Insurance Pre-authorization Notes (if applicable)

--- DOCUMENTATION & CHARTING ---
[ ] Summary of Patient Understanding of Treatment Plan
[ ] Date of Treatment Plan Discussion
[ ] Time of Treatment Plan Discussion
[ ] Doctor Signature
[ ] Patient Signature (if applicable)
[ ] Treatment Plan Shared Electronically (Y/N) (Yes, No)
[ ] Page Number of Treatment Plan in Chart

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