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 HistoryAll drugs the patient is taking

Gathering Data Cont.Medical History cont. Allergies

AnestheticLatexAntibiotics

Medical AlertEpilepsyDiabetesHeart 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 HistoryAlerts 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 PatientReview Medical Hx formSpeech problemsWalking problems

Examining the Patient

Methods of ExaminingPalpation:

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 PatientCheck: 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: 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:NeatlyAccuratelyIn PEN- Blue or Black

PATIENT CHART WRITE-UPSSOAP, 6-X’S SUBJECTIVE

Pt’s cc – all info given by pt

OBJECTIVE Observations made –

what is seen Actual facts & findings Radiograph

interpretation

ANALYSISDIAGNOSISTx optionsPARQ

Procedure, Alternatives, Risks, Questions

PATIENT CHART WRITE-UPSSOAP, 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 conditionsProvides pain relief

Level II – StandardRestores dental components to normal

functionAmal, Comp, Perio, FUD, PUD

Types of Treatment Plans

Level III – OptimumRestores dental components to maximum

function and estheticsCrowns & Bridges Inlays & OnlaysOrthodonticEndodontic Implants