TX Planning & Chart Write Up ACCURATELY

3 Major Steps in TX Planning 1. Data gathering 2. Examining the Patient 3. Preparing & presenting TX plans to PT

Gathering Data Personal Information- pt registration form Patient History  Includes personal info: name, phone #, SSN, physicians name & phone # Medical History  All drugs the patient is taking

Gathering Data Cont. Medical History cont. Allergies  Anesthetic  Latex  Antibiotics Medical Alert  Epilepsy  Diabetes  Heart Condition

Gathering Data Cont. Medical History cont. Medical Tests Rule of Thumb – ask more questions about any “yes” questions Patient MUST SIGN & DATE their Medical history form

Gathering Data Dental History  Alerts the DA & DR to concerns of the patients regarding previous care. Difficulty w/ Anesthetic Prosthetic devices that do not fit well Not being heard

Gathering Data Chief Complaint - ( CC ) Radiographs  BWX – PA’s – FMX Per Dr. policy Diagnostic Models

Examining the Patient Be observant as seating Patient  Review Medical Hx form  Speech problems  Walking problems

Examining the Patient Methods of Examining  Palpation: When the doctor uses his hands to feel for any abnormalities  Digital: Form of Palpation in which the fingers and thumb of one hand are used

Examining the Patient Check: Face  Symmetry  Asymmetry Lymph nodes  Look for lumps, bumps abnormalities Lips  Cracking & dryness Smile line  Look at where the lips are when the pt smiles Commissures  Cracking & dryness Temporal-mandibular Joint – listen for:  Pops, Clicks, Grinding

Examining the Patient Check: Tongue & Throat  Extend tongue and pull right and left  Use a 2x2 gauze to help hold tongue  Use mirror to check upper portion of throat for sores Floor of Mouth  Pt closes – palpate under chin & outer surface for lumps & bumps  Have Pt open & touch tongue to hard palate to examine floor of mouth, lingual frenum, salivary ducts

PATIENT CHART WRITE-UPS Always be sure to write in Pt’s chart:  Neatly  Accurately  In PEN- Blue or Black

PATIENT CHART WRITE-UPS SOAP, 6-X’S SUBJECTIVE  Pt’s cc – all info given by pt OBJECTIVE  Observations made – what is seen  Actual facts & findings  Radiograph interpretation ANALYSIS  DIAGNOSIS  Tx options  PARQ Procedure, Alternatives, Risks, Questions

PATIENT CHART WRITE-UPS SOAP, 6-X’S PROCEDURE  Actual TX preformed  Prescriptions  Types of Anesthetics given  Instructions or special care  Next Appt. 6 X’s: Hx – Health history Ex – Exam – (facts) Dx- Diagnosis (PARQ) Tx – Treatment Rx – Prescriptions Nx - Next

Remember Cavity Classifications Class I – Pit & fissure Class II – Posterior interproximal Class III – Anterior interproximal Class IV – Anterior, interproximal & incisal Class V – Cervical (gumline) Class VI – Abrasion/Attrition

Types of Treatment Plans Level I – Palliative (emergency)  Relieves distressful conditions  Provides pain relief Level II – Standard  Restores dental components to normal function  Amal, Comp, Perio, FUD, PUD

Types of Treatment Plans Level III – Optimum  Restores dental components to maximum function and esthetics  Crowns & Bridges  Inlays & Onlays  Orthodontic  Endodontic  Implants