Recording should include

• tooth number
• the type of restoration or treatment
• oral surgery
• dispensed medications
• prescribed medications
• over-the-counter (OTC) medications or supplements
• anesthetic used (if any)
• pre- and postoperative instructions (reviewed and understood by the patient)
• dental procedures (e.g., impressions, fluoride, vital signs)
• date
• operator
• assistant.

Process/Skill Questions:

• Why, or why not, do all recorded procedures require a tooth number?
• How should a multiple-tooth-restoration appointment be recorded?
• Why is it necessary to record all materials used in a procedure?
• How could waiting to record information be problematic?