Free resource
A free dental notes template in SOAP format, built for AHPRA compliance. Copy the dental notes template below, use it as a starting point, and check your own notes with the compliance tool at the bottom.
The SOAP dental notes template below covers every section the Dental Board of Australia expects in a clinical record. Copy it into your practice management software and fill in the fields for each appointment.
Dental notes template - SOAP format
DATE: [date] TIME: [time] CLINICIAN: [name], [provider number] PATIENT: [name] DOB: [date] S - Subjective Presenting complaint: [reason for attendance] Medical history reviewed: [any changes / nil changes] Medications: [list / nil] Allergies: [list / nil] O - Objective Extraoral: [findings / NAD] Intraoral soft tissue: [findings / NAD] Tooth [FDI number]: [clinical findings] BPE / perio findings: [if applicable] Radiograph: [type, tooth, justification] A - Assessment [Diagnosis / findings summary] P - Plan Treatment today: [procedure performed] Consent: [verbal / written] - risks and alternatives discussed LA: [agent] [concentration] [volume] mL, [technique], batch [number] Post-op instructions: [given verbally / written / nil required] Next appointment: [planned treatment / review / discharge]
This dental notes template uses FDI tooth numbering as required under AHPRA dental record standards.
The dental notes template above is structured around the AHPRA health records standard and the Dental Board of Australia shared Code of conduct. A complete dental notes entry must include:
Reason for attendance
What brought the patient in. Not just 'check-up' but the specific complaint or recall purpose.
Medical history review
Confirmed reviewed at this visit. Any changes documented. Medications and allergies up to date.
Clinical examination findings
Tooth-specific findings using FDI notation. Soft tissue, extraoral, perio findings if applicable.
Diagnosis
Clear statement of the clinical problem.
Consent
What was discussed, what alternatives were offered, that the patient agreed. Written for major procedures.
Local anaesthetic details
Agent, concentration, volume in mL, technique, batch number. All six fields are required.
Radiograph justification
Clinical justification documented at the time of exposure. Not 'routine'.
Treatment provided
Step-by-step account of what was done. Materials, specifications, outcomes.
Post-operative instructions
What the patient was told. Verbal or written. Nil if not applicable.
Follow-up plan
Next appointment purpose, or discharge if no further treatment.
This dental notes template example shows how to document a composite restoration. The format follows the AHPRA expectation that LA details, consent, and clinical justification are all recorded.
Dental notes template - composite
DATE: [date] CLINICIAN: [name] Reason: Caries tooth [FDI number] [surface] MH reviewed: nil changes Radiograph: [periapical/bitewing] [tooth] - caries [depth] Examination: Caries [surface] [FDI number], [size/depth], [pulp test result] Diagnosis: Caries [FDI number] requiring composite restoration Consent: Verbal - risks (postoperative sensitivity, need for future treatment if caries extends), alternatives (monitor, extraction) discussed. Patient consents. Treatment: LA: Articaine 4% with 1:100,000 adrenaline, 1.5 mL, buccal infiltration, batch [number] Rubber dam isolation Caries excavation complete Bonding agent applied, light cured Composite placed and light cured Occlusal check - patient comfortable [Surface] composite [FDI number] completed Post-op: Sensitivity possible 1-2 weeks, avoid hard foods today Review: 6/12 or prn
Before approving any dental note, check these items. This is the same checklist AHPRA investigators use when reviewing dental records in a complaint.
Paste one of your dental notes below. The checker scores it against AHPRA dental records standards and tells you exactly what is missing or weak.
Dental notes compliance checker
Paste a dental note to score it against the AHPRA dental records standard.
What should a dental notes template include?
A dental notes template for Australian dentists should include: date and time, treating clinician, patient medical history update, reason for attendance, examination findings, diagnosis, treatment provided, consent obtained, local anaesthetic details (agent, concentration, volume, batch, technique), radiograph clinical justification, post-operative instructions, and next appointment plan.
Is there a free dental notes template for Australian dentists?
Yes. The dental notes template on this page is free to copy and use. It follows the AHPRA health records standard and Dental Board of Australia expectations for clinical documentation.
What is SOAP format for dental notes?
SOAP dental notes are structured as: Subjective (what the patient reports), Objective (what the clinician finds on examination), Assessment (diagnosis), and Plan (treatment proposed and provided). This dental notes template format is widely used in Australian dental practices.
How do I write better dental notes?
Use a dental notes template and check each section before approving: reason for attendance is documented, medical history is reviewed, findings are recorded with tooth numbers in FDI notation, consent is documented with risks discussed, LA details are complete, and a follow-up plan is stated.
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