Dental-system
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Jatin Yadav
Jatin YadavCreate a AI-Powered Dental Clinic Operating System as centralized SaaS platform
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Sarah M. Thompson
PT-2024-00842Record Complete
92%Complete
Contact Information
Allergies & Alerts
PenicillinLatexSulfa Drugs
Emergency Contact
Patient Information Record
Medical History
Allergies, conditions & medications
9 items
Dental History
Treatments, implants & tooth chart
4 treatments
Insurance Information
Policy, coverage & benefits
80% coverage
Insurance Provider
BlueCross BlueShield Dental
Policy Number
BCBS-D-44821990
Group Number
GRP-7742-DEN
Member ID
MID-99234761
Annual Benefits
Annual Maximum
$2,000
Deductible (Met / Total)
$50 / $50
Coverage Types
Coverage Period
Jan 01, 2025 — Dec 31, 2025
Emergency Contacts
Next of kin & authorized contacts
2 contacts
ST
Sandra Torres
+1 (555) 827-4410
412 Maple Ave, Austin TX 78701
Spouse
CT
Carlos Torres
+1 (555) 391-0874
Same Household
Son
Consultation History
Complete timeline of patient visits and clinical encounters
6Total Visits
5Completed
1Pending
Jun 18, 2026Last Visit
Jul 3, 20263:30 PM
PendingComposite restoration review and occlusal bite check
Jun 18, 202610:30 AM
CompletedRoutine orthodontic adjustment and wire tightening
May 22, 20262:15 PM
CompletedTooth sensitivity and mild pain in lower right quadrant
Apr 10, 20269:00 AM
CompletedBroken bracket on upper left canine — emergency visit
Mar 5, 202611:00 AM
CompletedGum swelling and bleeding on brushing for past 2 weeks
Feb 14, 20261:00 PM
CompletedInitial orthodontic consultation and treatment planning
SOAP Notes
4 notes on record · 1 pending approval
1 Pending Review
MR
Pending Review
SSubjective— Patient Report
Patient reports mild discomfort along upper left quadrant following last arch wire adjustment 3 days ago. Rates pain at 3/10. No swelling noted. Patient is compliant with rubber band wear (18-20 hrs/day per patient report). Soft diet maintained.
OObjective— Clinical Findings
Intraoral exam: Upper arch wire seated properly. Mild gingival inflammation around #13 and #14. No bracket failures observed. Overjet reduced from 4mm to 2.5mm since last visit. Midline correction progressing — 1mm shift toward center. Panoramic X-ray reviewed; root resorption within acceptable limits.
AAssessment— Diagnosis
Orthodontic treatment progressing satisfactorily. Mild gingival inflammation secondary to plaque accumulation near appliances. Overjet correction on track per treatment timeline. No complications identified.
PPlan— Treatment Plan
Advance upper arch wire from 0.019x0.025 SS to 0.021x0.025 SS. Add Class II elastics bilaterally at 3/16" medium force. Reinforce oral hygiene instruction with proxy brush technique. Schedule follow-up in 6 weeks. Patient instructed to call if discomfort exceeds 5/10 or if bracket debonds.
JO
Approved
SSubjective— Patient Report
Patient presents for routine 6-month recall examination and prophylaxis. No chief complaint. Reports occasional sensitivity to cold beverages on lower right posterior region for approximately 2 weeks. No spontaneous pain. Last dental visit 6 months ago.
OObjective— Clinical Findings
Comprehensive oral exam performed. BPE scores: 0/1/1/1/0/0. Plaque index: 18% — improved from 32% at last visit. Radiographic exam: Bitewings reveal early interproximal caries at #30 mesial — estimated 1/3 enamel depth. No periapical pathology. Sensitivity testing: #31 responds within normal range; #30 shows mild hypersensitivity to cold (lingers 8 seconds).
AAssessment— Diagnosis
Early caries lesion #30 mesial requiring restorative intervention. Dentinal hypersensitivity #30 — likely related to early lesion. Overall periodontal health acceptable with improvement noted in oral hygiene compliance.
PPlan— Treatment Plan
Schedule composite restoration #30 mesial within 4 weeks. Apply fluoride varnish today — 5% NaF. Prescribe Sensodyne Repair & Protect for daily use. Recommend dental floss use between #29-30 nightly. Recall in 6 months with bitewing radiographs.
PS
Requires Revision
SSubjective— Patient Report
Patient referred by Dr. Rivera for periodontal evaluation prior to orthodontic continuation. Patient reports bleeding gums when brushing, especially in lower anterior region. History of moderate periodontitis diagnosed 18 months ago — treated with SRP. Non-smoker. No systemic conditions.
OObjective— Clinical Findings
Full-mouth periodontal charting completed. Average probing depths: 2-4mm throughout. Localized pockets of 5mm at #24 distal and #25 distal. BOP index: 22%. Recession: 1mm at #23 and #24 facial. Bone levels stable on periapical films compared to baseline radiographs from 18 months ago.
AAssessment— Diagnosis
Periodontal maintenance phase — generalized mild gingivitis with localized residual moderate periodontitis sites at #24-25. Stable bone levels indicate treatment response. Orthodontic continuation is appropriate with enhanced maintenance protocol.
PPlan— Treatment Plan
Perform site-specific SRP at #24 and #25 under local anesthesia. Prescribe chlorhexidine 0.12% rinse BID for 2 weeks. Increase periodontal maintenance to every 3 months during active orthodontic treatment. Re-evaluate in 8 weeks prior to orthodontic reactivation. Communicate findings to Dr. Rivera.
MR
Approved
SSubjective— Patient Report
Patient presents for monthly orthodontic adjustment. No complaints. Elastics worn as prescribed. Patient reports improvement in bite comfort compared to previous visit. Oral hygiene appears improved on inspection.
OObjective— Clinical Findings
All brackets intact. No wire breakage. Upper arch wire progressing — 0.017x0.025 NiTi in place. Lower arch torque expression improving. Anterior overbite: 2mm (reduced from 3mm). Molar relationship: Class I bilateral with slight Class II tendency on right. Space closure progressing as planned.
AAssessment— Diagnosis
Orthodontic treatment on schedule. Mid-treatment progress satisfactory. No active periodontal concerns noted today. Cooperative patient with good compliance.
PPlan— Treatment Plan
Advance lower arch wire to 0.019x0.025 NiTi. Adjust upper wire ties. Continue Class II elastics — right side only. Emphasize importance of elastic compliance for molar correction. Next appointment in 4 weeks for reassessment.
Clinical Record
Diagnoses
ICD-10 coded diagnoses, severity tracking, and clinical notes
7Total4Active3High Severity2Resolved
Status:
Severity:
| ICD-10 Code | Diagnosis | Date Diagnosed | Status | Severity | Notes | Actions |
|---|---|---|---|---|---|---|
| K09.0 | Dentigerous Cyst Associated with impacted tooth #48 (LR wisdom) | Jan 27, 2025 | Active | High | 6 | |
| K03.81 | Cracked Tooth Syndrome Tooth #36 — incomplete fracture, sensitive to cold | Feb 18, 2025 | Active | Medium | 5 | |
| K12.0 | Recurrent Oral Aphthae Minor aphthous ulcers — buccal mucosa bilateral | Mar 05, 2025 | Resolved | Low | 1 | |
| K08.101 | Complete Loss of Teeth Due to Trauma Tooth #21 avulsion — replantation attempted | Mar 30, 2025 | Resolved | Medium | 2 | |
| M26.20 | Temporomandibular Disorder TMJ dysfunction with lateral deviation on opening | Apr 14, 2025 | Monitoring | Medium | 3 | |
| K05.10 | Chronic Generalized Periodontitis Generalized — bone loss observed on OPG | May 22, 2025 | Active | High | 7 | |
| K02.9 | Dental Caries, Unspecified Upper right quadrant — multiple teeth affected | Jun 10, 2025 | Active | High | 4 |
Prescriptions
Active and historical medication records
3Active
2Expired
1Discontinued
2Refill Eligible
Filter:
to
Amoxicillin
Antibiotic — Capsule
MR
Dr. Maria Rivera
General Dentist
2 refills left
Ibuprofen
NSAID — Tablet
MR
Dr. Maria Rivera
General Dentist
Chlorhexidine Gluconate
Antiseptic Rinse — Oral Solution
JN
Dr. James Nakamura
Periodontist
Clindamycin HCl
Antibiotic — Capsule
MR
Dr. Maria Rivera
General Dentist
Triamcinolone Acetonide
Corticosteroid — Oral Paste
SC
Dr. Sarah Chen
Oral Medicine Specialist
Lidocaine Viscous
Local Anesthetic — Oral Solution
JN
Dr. James Nakamura
Periodontist
1 refill left
Imaging & Attachments
X-rays, CBCT scans, clinical photos, and documents
X-RayPanoramic_X-Ray_2024-05-12.jpg
CBCT — Preview unavailable
CBCTCBCT_Scan_Maxillary_2024-04-28.dcm
PhotoClinical_Photo_Facial_2024-05-02.jpg
X-RayPeriapical_X-Ray_UR6_2024-05-14.jpg
Document — Preview unavailable
DocumentReferral_Letter_Ortho_2024-03-20.pdf
PhotoIntraoral_Photo_Occlusal_2024-05-02.jpg
EMR Audit Log
HIPAA-compliant read-only audit trail for all electronic medical record modifications.
HIPAA Compliant — Read Only
12Total Entries
0Today
5Modifications
5Active Users
Action
From
To
| Timestamp | User | Action | Record Modified | Change Summary |
|---|---|---|---|---|
Jun 25, 2026 03:47 PM | SW Billing Sandra White | Modified Record | BIL-9940 Carlos Mendez — Payment Record | Applied partial payment of $850 to outstanding balance. Updated payment plan schedule. |
Jun 25, 2026 03:11 PM | JP Dr. James Patel | Created Note | EMR-20452 Priya Sharma — Orthodontic Assessment | Initial orthodontic assessment note created. Skeletal Class II discrepancy documented with photos. |
Jun 25, 2026 02:28 PM | SK Admin Sarah Kim | Modified Record | EMR-20420 Thomas Wright — Medical History | Updated hypertension medication list and dosage per physician consultation note received. |
Jun 25, 2026 01:52 PM | MR Dr. Maria Rivera | Approved Note | EMR-20449 Jennifer Adams — Periodontal Chart | Approved updated periodontal charting with new probing depth measurements. Signed electronically. |
Jun 25, 2026 01:05 PM | LC Nurse Lisa Chen | Uploaded Image | IMG-8829 David Park — CBCT Scan | Uploaded CBCT scan series (42 slices) for implant planning review. 3D reconstruction included. |
Jun 25, 2026 12:18 PM | SW Billing Sandra White | Modified Record | BIL-9934 Lisa Nakamura — Insurance Claim | Updated claim #9934 with corrected procedure codes D2740 and D6010. Resubmitted to Aetna. |
Jun 25, 2026 11:45 AM | JP Dr. James Patel | Created Note | EMR-20451 Robert Chang — Post-Op Note | Created post-operative note following molar extraction. Recovery instructions documented. |
Jun 25, 2026 11:02 AM | SK Admin Sarah Kim | Modified Record | EMR-20435 Aisha Okonkwo — Allergy Record | Added penicillin allergy with severity rating. Updated medication contraindications list. |
Showing 1 – 8 of 12 entries
This audit log is read-only. No modifications are permitted to ensure compliance integrity. All entries are cryptographically signed and tamper-evident.
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