TX Planning & Chart Write Up

1. TX Planning & Chart Write Up ACCURATELY

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

3. 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

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

5. 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

6. 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

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

8. Examining the Patient • Be observant as seating Patient • Review Medical Hx form • Speech problems • Walking problems

9. 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

10. 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 PatientCheck:

11. 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 Examining the PatientCheck:

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

13. 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-UPSSOAP, 6-X’S

14. 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 PATIENT CHART WRITE-UPSSOAP, 6-X’S

15. 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

16. 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

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