OpenDentist NotesAI clinical notes for oral surgery procedures
Surgical procedures require precise documentation — from the initial assessment and consent discussion through to the operative technique and post-operative instructions. OpenDentist captures everything from your natural speech, generating structured surgical notes that are thorough and medicolegally sound.
Surgical assessment documentation
A thorough pre-operative assessment is the foundation of safe oral surgery. OpenDentist captures the clinical detail that matters.
Medical history and risk assessment
When you review the medical history with your patient, the AI captures relevant conditions — anticoagulant therapy (warfarin, DOACs, aspirin), bleeding disorders, bisphosphonate use (MRONJ risk), immunosuppression, cardiovascular conditions, and diabetes status. The system flags when these are mentioned and ensures they appear prominently in the notes alongside any risk mitigation measures discussed.
Radiographic assessment
Describe your radiographic findings — root morphology (curved, dilacerated, hypercementosed roots), proximity to the inferior alveolar nerve or maxillary sinus, degree of impaction (mesio-angular, disto-angular, horizontal, vertical), Pell and Gregory classification, Winter classification, and bone density assessment. The AI documents these findings and links them to your surgical plan.
Consent documentation
Thorough consent documentation is critical in oral surgery. The AI records exactly what risks, benefits, and alternatives you discussed with the patient.
Risks discussed
When you explain the risks of the procedure to your patient — pain, swelling, bleeding, infection, dry socket, nerve damage (temporary or permanent paraesthesia or anaesthesia of the inferior alveolar nerve or lingual nerve), oro-antral communication, damage to adjacent teeth, or jaw fracture — the AI captures each risk that was mentioned. This creates a clear record that the Montgomery duty of consent was met.
Alternatives and benefits
The AI documents alternative treatment options discussed (such as coronectomy instead of full extraction for high-risk third molars, or monitoring rather than immediate intervention), the benefits of the recommended treatment, and the consequences of no treatment. The patient's understanding and agreement are noted.
Capacity and understanding
For complex procedures, documenting that the patient has capacity to consent and demonstrated understanding is important. When you confirm understanding during the conversation, the AI captures this. For patients under 16, the AI notes whether consent was provided by a parent or guardian and whether Gillick competence was assessed.
Operative notes and post-op instructions
After the procedure, dictate what happened and what instructions were given. The AI turns it into structured operative documentation.
Surgical technique
Document the anaesthetic used (type, volume, and site), whether a flap was raised (envelope, triangular, or trapezoidal), bone removal method and extent, tooth sectioning approach, delivery technique, socket management (curettage, irrigation, haemostatic agents), and closure (suture type, technique, and number). The AI structures each element into a clear operative record.
Post-operative instructions
When you give the patient their post-op instructions — bite on gauze, avoid rinsing for 24 hours, salt water rinses from the next day, soft diet, analgesic advice (paracetamol and ibuprofen dosing), signs to watch for (increasing pain, excessive bleeding, swelling, raised temperature), and when to contact the practice — the AI documents everything that was discussed, creating a record that matches the verbal instructions given.
Extraction complexity grading
The AI recognises when you describe the difficulty of an extraction — straightforward forceps extraction versus surgical extraction with bone removal and tooth sectioning. Factors like ankylosis, root fracture during extraction, unexpected complications, and the time taken are captured. This is particularly important for NHS claims where the complexity determines the treatment band.
Follow-up planning
Document the follow-up plan — whether suture removal is needed (and when), review appointments, referral for histopathology if a biopsy was taken, and any prescriptions issued (antibiotics, chlorhexidine mouthwash, analgesics). The task extraction feature automatically creates follow-up tasks from these instructions.
Example oral surgery note sections
A typical AI-generated oral surgery note includes these structured sections.
Try AI oral surgery notes free
28-day free trial with full access. Build a custom surgical template or start with the flexible default.
Start Free Trial