---
{"title": "How to record exam findings for dentists in 2026", "description": "A plain guide for dentists to record exam findings, with steps, the tools to try and the mistakes to avoid.", "url": "https://xpdaily.com/how-to-record-exam-findings-for-dentists/", "date": "2026-10-23"}
---
A plain guide for dentists to record exam findings, with steps, the tools to try and the mistakes to avoid.

Record each finding at the moment you examine it, tie it to the tooth or area it describes, and save it in the patient's permanent record before you move on. You can write it by hand, type it, or dictate it into any window. This page also covers QuickDictate, a dictation tool made by the team that publishes this site, as one way to capture findings.

| Approach | How it captures exam findings |
|---|---|
| Paper chart | You write each finding as you examine it, by hand |
| Practice record software | You type or paste findings into the notes field, if entry speed suits the exam |
| QuickDictate | Windows program that types what you say into whichever window is in focus [^1] |

## What you need before you start

Recording exam findings takes only a few things, most of them already in the surgery.

- **A place to put the findings.** The patient's chart, the practice's record software, or a paper sheet all work. What matters is that the record ends up in one agreed place.
- **A way to name teeth and surfaces.** Decide on one system before the appointment. Tooth numbers, names, or a diagram all work as long as every finding names the tooth or area it belongs to.
- **A list of what the exam checks.** The findings follow the order of the exam: teeth, gums, soft tissue, and anything else the practice records. Keep the list beside you.
- **A way to capture while you work.** You can write, type, or speak into a dictation tool. Choose the one that does not slow the exam.
- **A naming convention for findings.** Short, plain words such as caries, fracture or recession keep the record consistent and easy to read later.
- **A routine for saving.** Decide when the record is signed and stored, and do it before the next patient.

Set up the record and the tooth naming before the patient sits down. Deciding these on the spot slows the exam.

## Step by step

These steps work with any tool, including a pen and paper.

1. **Open the patient's record before the exam starts.** Make sure you can reach it and that it holds the previous findings you will compare against.
2. **List the areas the exam will check.** Write the order in one line: teeth, then gums, then soft tissue. This keeps the record complete.
3. **Check and record one area at a time.** Examine the tooth or region, then record the finding before you move to the next one.
4. **Name every finding.** Each line ties the finding to a tooth number or named area, so nothing floats without a home.
5. **Keep the words plain.** Use the same short terms for the same findings across patients, so later readers can compare.
6. **Say the finding aloud if you dictate.** With dictation, speak the finding when you reach it, then move on.
7. **Check the record against the exam list.** Read the notes once from top to bottom and fill in anything the exam covered but the notes missed.
8. **Note anything abnormal separately.** Flag findings that need follow-up, and write the plan for them in the same record.
9. **Save the record.** Store it in the agreed place and close the session before the next patient.
10. **Review the record after the appointment.** A quick read the same day catches a garbled word or a missing surface.

## Tools that can do it

You do not need software for this. Here are options to consider.

**Paper chart.** You write each finding on the chart as you examine it. Nothing is published here about price or limits because it depends on what the practice already has.

**The practice's record software.** Most dental records already live in some form of software. Check whether its note entry lets you type at the speed the exam needs, and how its records are kept.

**QuickDictate.** QuickDictate is made by the team that publishes this site. QuickDictate is one option for capturing findings in plain text. It is a Windows program that types what you say into whichever window you are using. [^1] You hold a key while you talk, or press it once to start and once to stop, and you can change both keys. [^1] What you say is typed into whichever window has focus, such as the practice's note field or a text editor. [^1]

QuickDictate uses a cloud provider for speech recognition, and you can use ElevenLabs, Deepgram, OpenAI, AssemblyAI, DashScope or Google, and that provider bills you directly. [^1] To work without the cloud, choose Local in Settings and install a speech model such as Whisper Large v3 Turbo; dictation then needs no internet connection or API key. [^1] With five of the cloud providers, words appear while you are still talking. [^1] You can list words and phrases that are sent to the provider to help it recognise them, and a replacement table fixes spellings such as "Chat GPT" to "ChatGPT". [^1] Profiles can change the provider, language, vocabulary and formatting depending on which app is in focus. [^1] You can browse and filter your last 50 dictations in Settings, and the history survives a restart or self-update. [^1] Saying "scratch that" discards the text you just dictated instead of inserting it, and it is the only voice command shipped. [^1] While you are dictating, other apps' audio is muted or turned down, and it goes back to its old level when you stop. [^1]

If you sign in, you can sync preferences such as hotkeys and language between PCs, and API keys, audio and transcripts are never synced. [^1] QuickDictate is free for personal and other noncommercial use, with no subscription or account, and cloud providers bill you separately for their service. [^1]

QuickDictate runs only on 64-bit Windows 10 and 11, and there is no Mac or Linux version. [^1] It is delivered as an .exe file on GitHub, with a built-in updater that works silently, and it can also be built from source. [^1]

## Common mistakes to avoid

**Recording findings at the end of the day.** Recalling a whole exam from memory loses detail. Record each finding while the patient is still in the chair.

**Skipping the tooth name.** A finding without a tooth number cannot be acted on later. Tie every line to an area.

**Changing words between patients.** If one visit says caries and the next says decay, comparisons get harder. Stick to one term per finding.

**Forgetting to check the dictated text.** A speech tool can mishear a term. Read the recorded note before you save it and fix any wrong word.

**Not saving before moving on.** An unsaved note can be lost when the next patient arrives. Save the record before you close the screen.

**Using the exam list from memory.** Working without the list invites a skipped surface. Keep the checklist beside you and mark each step.

## Frequently asked questions

### Can QuickDictate type into a dental chart?

QuickDictate types what you say into whichever window has focus, such as an editor, a chat box or a web form. [^1] That opens the door to having exam findings typed into the practice's note field. Whether it can reach a given chart depends on that program's own windows, so check how the practice's software shows its note entry before relying on it.

### Does QuickDictate need the internet?

QuickDictate normally uses a cloud provider for speech recognition, and the provider bills you directly for its service. [^1] To avoid the cloud, choose Local in Settings and install a speech model such as Whisper Large v3 Turbo, and dictation then needs no internet connection or API key. [^1] Pick whichever fits where the exam happens.

### Is QuickDictate free for dental practices?

QuickDictate is free for personal and other noncommercial use, with no subscription or account, and cloud providers bill you separately for their service. [^1] Commercial use needs a separate licence. [^1] A dental practice charging for its services counts as commercial, so check the licence terms before using it on practice income.

### Can QuickDictate fix dental terms it mishears?

QuickDictate lets you list words and phrases that are sent to the provider to help it recognise them, and a replacement table fixes spellings such as "Chat GPT" to "ChatGPT". [^1] That helps with the plain terms a dentist repeats. Even so, read the recorded note and correct any wrong word before saving, since the tool still depends on the speech provider for exact recognition.

### Which Windows does QuickDictate run on?

QuickDictate runs only on 64-bit Windows 10 and 11, and there is no Mac or Linux version. [^1] It is delivered as an .exe file on GitHub, with a built-in updater that works silently, and it can also be built from source. [^1] Confirm the practice computers are 64-bit Windows 10 or 11 before planning to use it on them.

QuickDictate is free for personal and other noncommercial use, with no subscription or account. Cloud providers bill you separately for their service. [^1] - [Visit QuickDictate](/go/start)

## Sources

[^1]: QuickDictate's own description of itself (the product of this site's publisher) (/go/start)