Individual skill

dental-clinical-note

Write a dental chart note that survives an insurance audit, a recall years later, and a colleague picking up the case cold — the finding, the justification, the consent conversation, and the materials, in the order a reviewer looks for them. Use when asked to write a chart note, document a procedure, improve clinical documentation, or when a claim was denied for insufficient documentation. Produces a structured note with subjective, objective, assessment and plan, the medical necessity justification, consent documented, materials and lot numbers, and the next-visit plan. Documentation support only; the clinical content is the treating clinician's.

skills/dental-clinical-note/SKILL.md

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# Dental Clinical Note

A chart note is read three times: by you next visit, by an insurer deciding whether to pay, and — rarely, and badly — by a lawyer. Most notes serve the first reader and fail the other two. This writes the note that holds up: what was found, why treatment was necessary, what the patient was told and agreed to, and what was actually used.

## What This Skill Produces

- **A structured SOAP note** — subjective, objective, assessment, plan, in the order a reviewer scans
- **The medical-necessity justification** — the specific finding that made this treatment indicated, which is what a denied claim usually lacks
- **Consent documented** — what was explained, the alternatives offered, the risks stated, and that the patient agreed
- **Materials and technique** — anaesthetic type and amount, materials, shades, lot numbers where required
- **The next-visit plan** — what follows, when, and what to check
- **An audit-readiness flag** — what in this note an insurer or reviewer would question

## Required Inputs
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