What MUST be included in your endo note?

• A. CC, hx of symptoms; Review of med hx; Exam findings (clinical, radiographic); Pulp testing results; Pulpal and Periapical Diagnoses; Tx options, risks, benefits, costs discussed; Consent obtained; Local Anesthetic (amount and how delivered); RDI; Canals and what length/size/taper prepared to; Irrigants used (NaOCl); Obturation material and sealer; Restoration placed (temp or permanent) and material(s) used; Whether or not there is a cotton pellet under the temporary restoration; Total # of radiographs exposed; Post-op instructions; Recall interval; Next visit
• B. CC and symptoms only
• C. Exam findings only
• D. Pulp testing results only

Answer: (A)

A complete endodontic note must capture the entire clinical narrative from presentation to plan and outcome, not just the procedure itself. It should document the patient’s chief complaint and history of present illness, plus past medical history, and then record the exam findings (both clinical and radiographic) that establish the baseline. It needs to include the pulp testing results and the pulpal and periapical diagnoses, showing how you arrived at the treatment plan.

Beyond diagnosis, the note should reflect the discussion of treatment options with their risks, benefits, and costs, and confirm that informed consent was obtained. For the procedure itself, include anesthesia details (amount and method), specifics about canal preparation (length, size, taper), and the irrigation strategy. Record the obturation material and sealer, the final restoration placed (whether temporary or permanent) and the materials used, and whether a cotton pellet was under the temporary restoration. Also note the total number of radiographs exposed and include post-operative instructions, recall interval, and the next visit.

This level of detail matters because it ensures continuity of care, supports informed decision-making, and provides defensible documentation for professional and legal purposes. It shows the diagnostic reasoning, treatment choices, materials and techniques used, and the plan for follow-up, all of which would be missing if you only documented isolated elements such as history, exam, or test results.