Transcript TX Planning & Chart Write Up

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
 Per
– PA’s – FMX
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
 Look
at where the lips
are when the pt smiles
 Asymmetry

Lymph nodes

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Lips
 Cracking
& dryness
Commissures
 Cracking
 Look
for lumps, bumps
abnormalities
Smile line

& 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
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
 Pt
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.
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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