Free Tooth Extraction Clinical Note Template
Extraction documentation is high-risk medico-legally. This template covers every required step — anesthesia, technique, socket care, hemostasis — so you never miss a detail in a rushed appointment.
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Replace each [bracketed field] with your specific clinical detail. Brackets are placeholders — they don't get saved into the chart.
Simple extraction #[14]. Local anesthesia: [1.5] carpule(s) of [4% Septocaine 1:100k epi] via [buccal infiltration]. Adequate anesthesia confirmed. Periosteal elevator used to separate gingiva. Straight elevator used to luxate. Extracted with forceps. Site inspected, granulation tissue removed, irrigated with NS. Hemostatic pack placed. Patient tolerated procedure well. Post-operative instructions given.
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When to use this template
Use this template after any simple (non-surgical) extraction of a permanent or primary tooth. The template covers anesthesia, periosteal elevation, luxation, forceps delivery, socket inspection and irrigation, and hemostatic-pack placement. For surgical extractions (impacted thirds, sectioning required, flap reflection), use a separate surgical-extraction template — the documentation requirements differ. Always specify the tooth number, anesthesia type and volume, and whether socket preservation (graft) was performed.
Tips for using this template
- check_circleSpecify the elevator and forceps type for surgical defensibility — "straight elevator" and "#150 forceps" are clearer than "elevator and forceps".
- check_circleDocument socket inspection explicitly. "Site inspected, granulation tissue removed" demonstrates standard of care.
- check_circleIf the tooth fractured during extraction, add "Tooth fractured during luxation; root tips removed atraumatically." Don't hide it.
- check_circleFor socket preservation, add: "Socket preservation performed with [Allograft / Xenograft]. Membrane placed if applicable."
- check_circleAlways note hemostasis: "Hemostatic pack placed" or "Bleeding controlled with pressure and gauze." Insurance audits flag missing hemostasis docs.
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