DCRR-2026 · Public domain · Free forever

Dental Clearance Response Record

A record of what a dentist observed on a date, returned to the team that asked. It documents an observation. It does not grant permission, and it never will.

Draft for comment · Not a standard

Chapter 01

The record

Copy it, print it, fax it, put it in your own software. No fee, no account, no permission required, and no attribution obligation beyond honesty about which version you used.

Dental Clearance Response Record DCRR-2026 · Draft for comment

RETURN TO: ______________________ REPLY BY: ____/____/______

PATIENT REFERENCE: ______________ DATE OF BIRTH: ____/____/______
(from the referral. Do not add the patient's name.)

REFERRING CLINICIAN: ____________________ NPI: ______________

EXAMINATION DATE: ____/____/______ RADIOGRAPHS: [ ] Yes [ ] No [ ] Prior images reviewed

What was observed (check one)

No active oral infection identified on examination. Date examined: ____/____/______

Active infection treated and resolved. Treatment completed: ____/____/______ No active oral infection identified as of that date.

Treatment required and not yet complete. What is required: ______________________________
Estimated ready date: ____/____/______
Patient's decision on treatment: [ ] willing [ ] declined

Unable to complete an adequate assessment. Reason: ______________________________________
Limited opening, patient could not tolerate the exam, imaging not obtainable. This is a real finding, not a failure.

Patient did not present. Last contact attempt: ____/____/______

Unable to accept this referral. No reason required. Returning this box today is more useful than silence for three weeks.

What this record is

This form documents what was observed on a specific date. It does not recommend proceeding to surgery, delaying surgery, or any other action. The medical team holds the decision on timing and risk.

It does not attest to fitness for anesthesia, fitness for the planned procedure, surgical risk, or any finding after the examination date.

DENTIST: ____________________________ NPI: ______________
SIGNATURE: __________________________ DATE: ____/____/______

DCRR-2026, draft for comment. Not a standard. Inter-rater reliability is unmeasured and the population is not yet defined. referralright.com/dcrr · Public domain.

What is not settled lists every open question, on purpose. A clinician checking this will look for that first.

Chapter 02

Why it is shaped this way

Six clinical instruments that failed were examined against two that lasted fifty years or more. Every failure died the same way: an observation was treated as a recommendation.

The word that had to go

An earlier draft said CLEARED. That is a permission, and a permission is the defect. Every outcome here states what was seen, with a date. The medical team decides what it means.

Sixteen years

The 0 to 10 pain scale arrived in the 1990s as an observation, was mandated in 2000, and was formally withdrawn by the AMA, ACS, Joint Commission and CMS in 2016. The scale was sound. What was attached to it was not.

One motion

Roughly four in five patients have nothing wrong. Splitting this into four separate judgements was proposed and rejected: it would tax the common case to serve the rare one, and an uncompleted form is the status quo we are trying to replace.

Chapter 03

What is not settled

Three of the eight properties that separate durable instruments from failed ones are open. Calling a draft a standard is precisely how instruments die, so they are published rather than buried.

Inter-rater reliability is unmeasured: No kappa has been calculated. Two competent dentists already disagree by inspection on whether a chronic asymptomatic periapical lesion is an active infection, and this sheet supplies no definition. Target before this stops being a draft: kappa of 0.80 or better, measured with clinicians outside the authoring team.
The population is undefined: Head and neck radiation is not the same clinical problem as cardiac valve replacement. A scoped instrument that admits its scope is better than a universal one that is wrong for a population.
Free-text containment is unproven: "What is required" and "Reason" must elaborate an outcome and never determine it. The checked box is the datum; the text is context.
One problem has no paper solution: No wording prevents an integration layer collapsing this record into a single true or false flag. The careful language would then show that nobody lied, while the flag shows the hospital treated it as permission. That needs a rule about what a conforming integration may assert, which is a separate artifact from this sheet.

Chapter 04

Citation and licence

Placed in the public domain. No copyright is asserted and no permission is required to reproduce, translate, display, distribute, embed in software, print on letterhead, or include in a commercial product.

Dental Clearance Response Record (DCRR-2026), draft for comment.
Guident, 2026. Public domain. referralright.com/dcrr

Every published version stays permanently retrievable at its own address. This one lives at referralright.com/dcrr/2026 and will stay there after it is superseded, because a sheet in a fax library does not update itself. Superseding is not deletion.

Colophon

The comments that would change this most are the ones saying a box has no honest answer for a real patient you saw. Both holes found so far came from exactly that. See how a case closes, or read the dentist side.

DCRR-2026 is published by Guident and placed in the public domain. It is free, it will stay free, and it will never acquire a fee, a registration, an account, or a permission step.