Documentation should include the following:

• Recording existing restorations and missing teeth
• Charting findings (in all current formats), such as areas of inflammation; types of oral lesions and conditions; developmental defects; diseases of the teeth; and pulp, periodontal, and TMJ disorders
• Recording the diagnosis
• Listing treatment(s) as determined by a dentist

Process/Skill Questions:

• How does one respond to a patient who asks for clarification of the dentist's instructions?
• How does one respond to a patient who asks for advice on treatment options?