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THE ODTP PROCESS A Case-Based Overview Orientation to the Clinical Practice of General Dentistry, Fall Quarter Alan W. Budenz, MS, DDS, MBA.

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Presentation on theme: "THE ODTP PROCESS A Case-Based Overview Orientation to the Clinical Practice of General Dentistry, Fall Quarter Alan W. Budenz, MS, DDS, MBA."— Presentation transcript:

1 THE ODTP PROCESS A Case-Based Overview Orientation to the Clinical Practice of General Dentistry, Fall Quarter Alan W. Budenz, MS, DDS, MBA

2 Heather – a new patient Screened by faculty September 26, 2005 Screened by faculty September 26, 2005 Designated as a 2 nd Year teaching case Designated as a 2 nd Year teaching case

3 Chief Concern (CC): I would like a bridge for my lower front teeth

4 The ODTP Process: Step 1 Preparation Pre-appointment preparation Pre-appointment preparation Review chart Review chart Read screening and/or treatment notes Read screening and/or treatment notes Review health history Review health history Review radiographs Review radiographs Make notes Make notes Plan out the first appointment Plan out the first appointment

5 The Pacific Health History Questionnaire Form - Comprehensive - Standardized - Translations

6 The Pacific Health History Questionnaire Form Section 1: General Questions Section 1: General Questions Designed to elicit general information about the patient’s health, and whether they have seen a physician recently, are currently in pain, or have had any problems with prior dental treatment. Designed to elicit general information about the patient’s health, and whether they have seen a physician recently, are currently in pain, or have had any problems with prior dental treatment.

7 The Pacific Health History Questionnaire Form Section 2: Signs and Symptoms Section 2: Signs and Symptoms Focuses on various signs and symptoms that are indicative of medical problems. Focuses on various signs and symptoms that are indicative of medical problems. Signs = indications of disease that can be observed by the practitioner. Signs = indications of disease that can be observed by the practitioner. Symptoms = problems associated with a disease that are experienced by the patient, but cannot be seen by the practitioner. Symptoms = problems associated with a disease that are experienced by the patient, but cannot be seen by the practitioner.

8 The Pacific Health History Questionnaire Form Section 2: Signs and Symptoms Section 2: Signs and Symptoms Note: No time frame is specified for any of these signs or symptoms. Note: No time frame is specified for any of these signs or symptoms. Determining the relevance of the time frame is the responsibility of the practitioner. Determining the relevance of the time frame is the responsibility of the practitioner.

9 The Pacific Health History Questionnaire Form Section 3: Specific Diseases Section 3: Specific Diseases Concentrates on specific diseases which have been previously diagnosed by a physician. Concentrates on specific diseases which have been previously diagnosed by a physician. All of these diseases have a systemic effect. All of these diseases have a systemic effect. Therefore, all of these diseases have potential ramifications on dental care delivery. Therefore, all of these diseases have potential ramifications on dental care delivery.

10 The Pacific Health History Questionnaire Form Section 3: Specific Diseases Section 3: Specific Diseases The patient’s physiology is compromised by their medical problems, and many dental procedures have a significant physiologic impact. The patient’s physiology is compromised by their medical problems, and many dental procedures have a significant physiologic impact. Therefore, the dental procedure may need to be modified to insure patient safety. Therefore, the dental procedure may need to be modified to insure patient safety.

11 The Pacific Health History Questionnaire Form Section 4: Treatments Section 4: Treatments Discusses medical treatments and prosthetic devices which may have a bearing on dental management of the patient. Discusses medical treatments and prosthetic devices which may have a bearing on dental management of the patient. Decisions regarding dental management depend on the patient’s specific situation and the extent of the treatment and/or resultant outcome. Decisions regarding dental management depend on the patient’s specific situation and the extent of the treatment and/or resultant outcome.

12 The Pacific Health History Questionnaire Form Section 5: Medications and Drugs Section 5: Medications and Drugs Elicits important information on prescription drugs, over-the-counter medications, natural remedies, and any other drugs the patient might be taking. Elicits important information on prescription drugs, over-the-counter medications, natural remedies, and any other drugs the patient might be taking. Documents the extent of any problems noted on other parts of the health history, or possibly problems not identified by the patient. Documents the extent of any problems noted on other parts of the health history, or possibly problems not identified by the patient.

13 The Pacific Health History Questionnaire Form Section 6: Women Only Section 6: Women Only Elicits specific information relative to women uniquely. Elicits specific information relative to women uniquely. Pregnancy and the use of birth control pills are especially pertinent to dental care delivery. Pregnancy and the use of birth control pills are especially pertinent to dental care delivery.

14 The Pacific Health History Questionnaire Form Section 7: All Patients Section 7: All Patients Consists of a catch-all question designed to elicit information the patient feels is appropriate to provide, but which has not been otherwise directly queried. Consists of a catch-all question designed to elicit information the patient feels is appropriate to provide, but which has not been otherwise directly queried.

15 The Pacific Health History Questionnaire Form Patients should sign and date the health history after initially completing it. Patients should sign and date the health history after initially completing it. The patient should review, update, and re-sign the form at each recall visit. The patient should review, update, and re-sign the form at each recall visit. At start of each appointment, ask “Have there been any changes in your health?” Note response in the treatment record. At start of each appointment, ask “Have there been any changes in your health?” Note response in the treatment record.

16 The Health History Form In our clinic, the patient fills out a medical questionnaire when they first register. In our clinic, the patient fills out a medical questionnaire when they first register. This must be followed up with a verbal interview by the student doctor This must be followed up with a verbal interview by the student doctor To insure that the patient properly understood the questions To insure that the patient properly understood the questions To ask about and obtain a history about any positive responses To ask about and obtain a history about any positive responses To insure that a negative response was what the patient intended for certain questions. To insure that a negative response was what the patient intended for certain questions.

17 The Pacific Health History Interview Sheet The Pacific Health History Interview Sheet

18 The Health History Interview Form The separate interview sheet provides a location for notation of any significant findings and a description of any dental management considerations. The separate interview sheet provides a location for notation of any significant findings and a description of any dental management considerations. It is best not to alter or make notations on the patient’s Health Questionnaire form. It is best not to alter or make notations on the patient’s Health Questionnaire form. The interview sheet is used to ensure that any positive questionnaire responses are followed up and appropriately documented. The interview sheet is used to ensure that any positive questionnaire responses are followed up and appropriately documented.

19 The Pacific Health History Interview Form Includes 6 questions that need to be verbally asked of every patient: Do you have any… Includes 6 questions that need to be verbally asked of every patient: Do you have any… Cardiovascular problems? Cardiovascular problems? Infectious diseases? Infectious diseases? Allergies to medicines (or latex)? Allergies to medicines (or latex)? Bleeding problems? Bleeding problems? Take any medications? Take any medications? Other medical problems not asked about? Other medical problems not asked about?

20 The Pacific Health History Interview Form Cardiovascular problems? Cardiovascular problems? Infectious diseases? Infectious diseases? Allergies to medicines (or latex)? Allergies to medicines (or latex)? Bleeding problems? Bleeding problems? Take any medications? Take any medications? Other medical problems not asked about? Other medical problems not asked about? The six areas covered by these questions are extremely important to the dentist and it is appropriate to ask them again to insure that the patient properly understands and correctly answers the questions.

21 The Pacific Health History Interview Form Cardiovascular problems? Cardiovascular problems? Comprise the bulk of medical problems that require dental management considerations. Comprise the bulk of medical problems that require dental management considerations. 51% of patients with medical complexities have CV problems with the incidence rapidly increasing with age. (Smeets et al, Preventative Medicine 1998) 51% of patients with medical complexities have CV problems with the incidence rapidly increasing with age. (Smeets et al, Preventative Medicine 1998) Heart disease is the leading cause of adult deaths in the U.S. Heart disease is the leading cause of adult deaths in the U.S. Stroke is the third leading cause of death in adults in the U.S. Stroke is the third leading cause of death in adults in the U.S.

22 Most specifically, patients should be asked if they have any history of “heart problems or heart murmurs”. If “yes”, questions to ask: If “yes”, questions to ask: When was the problem first diagnosed? When was the problem first diagnosed? Did your doctor ever say you should take antibiotics before dental treatment? Did your doctor ever say you should take antibiotics before dental treatment? Did your doctor ever say you don’t need to take antibiotics before dental treatment? Did your doctor ever say you don’t need to take antibiotics before dental treatment? For heart murmurs specifically: Was it termed functional or organic? Is there regurgitation? For heart murmurs specifically: Was it termed functional or organic? Is there regurgitation?

23 The Pacific Health History Interview Form Infectious diseases? Infectious diseases? Hepatitis is the most common infectious disease with implications for dental complications. Hepatitis is the most common infectious disease with implications for dental complications. HIV+ and AIDS often produce significant oral and systemic changes. HIV+ and AIDS often produce significant oral and systemic changes. Note: All patients should be treated as though they are infectious, i.e. universal precautions are the standard infection control protocol for all patients, with one exception... Note: All patients should be treated as though they are infectious, i.e. universal precautions are the standard infection control protocol for all patients, with one exception...

24 The Pacific Health History Interview Form Infectious diseases? Infectious diseases? The one exception... The one exception... Active tuberculosis requires additional precautions, and these patients should generally be treated only in a hospital isolation facility.

25 The Pacific Health History Interview Form Allergies to medicines (or latex)? Allergies to medicines (or latex)? Patients should be asked about allergies to any medications in general, and specifically about possible allergies to: Patients should be asked about allergies to any medications in general, and specifically about possible allergies to: Antibiotics Antibiotics Pain medications, including aspirin Pain medications, including aspirin Narcotics Narcotics Local anesthetics Local anesthetics Latex Latex

26 The Pacific Health History Interview Form Hematologic, bleeding problems? Hematologic, bleeding problems? Has the patient ever had any bleeding problems or do they bruise easily? Has the patient ever had any bleeding problems or do they bruise easily? Positive responses may be indicative of undiagnosed hematologic disease. Positive responses may be indicative of undiagnosed hematologic disease. Referral to or consultation with the patient’s physician may be indicated. Referral to or consultation with the patient’s physician may be indicated.

27 The Pacific Health History Interview Form Take any medications? Take any medications? Indicates that the patient’s medical problems are severe enough to require medical treatment. Indicates that the patient’s medical problems are severe enough to require medical treatment. Knowing any medications that the patient may be taking allows the dentist to be alert to possible side effects, toxicity, or drug interactions that may occur during dental care. Knowing any medications that the patient may be taking allows the dentist to be alert to possible side effects, toxicity, or drug interactions that may occur during dental care.

28 The Pacific Health History Interview Form Take any medications? Take any medications? The increasing use of over-the-counter, natural, and herbal medications and supplements may have a significant impact on the delivery of dental care. The increasing use of over-the-counter, natural, and herbal medications and supplements may have a significant impact on the delivery of dental care. Patients often fail to disclose these medications unless specifically asked about them. Patients often fail to disclose these medications unless specifically asked about them.

29 The Pacific Health History Interview Form Other medical problems not asked about? Other medical problems not asked about? This catch-all question asked in a one-on-one confidential setting may elicit significant information that a patient may be reluctant to write down on a form. This catch-all question asked in a one-on-one confidential setting may elicit significant information that a patient may be reluctant to write down on a form. May also induce the patient to discuss anxieties and concerns they may have regarding dental treatment. May also induce the patient to discuss anxieties and concerns they may have regarding dental treatment. Allows dentists to establish a thoughtful and caring rapport with their patients. Allows dentists to establish a thoughtful and caring rapport with their patients.

30 The ODTP Process: Step 1 Medical History Review “Yes” answer to #3: Hospitalized or serious illness (3yrs) Listed: Lung problem What questions do you want to ask?

31 The ODTP Process: Step 1 Medical History Review “Yes” answers to #4: Being treated by physician Listed: Anemia, GERD What questions do you want to ask?

32 The ODTP Process: Step 1 Medical History Review “Yes” answers to #37: Stomach problems, ulcer What questions do you want to ask?

33 The ODTP Process: Step 1 Medical History Review “Yes” answers to #62: Taking medications Listed: Warfarin, Prevacid What questions do you want to ask?

34 The ODTP Process: Step 1 Medical History Review “Yes” answers to #63: Tobacco #63: Tobacco What questions do you want to ask?

35 Health History Review From your analysis of the medical history: From your analysis of the medical history: Is the patient’s medical condition controlled and stabilized under the supervision of a physician? Do you need to make any care delivery accommodations because of the patient’s health status?

36 Dental Management of Medically Complex Patients Good sources for information on this subject: Good sources for information on this subject: From the UOP web site: From the UOP web site: Protocols for the Dental Management of Medically Complex Patients Protocols for the Dental Management of Medically Complex Patients Protocols for the Dental Management of Patients with HIV Disease Protocols for the Dental Management of Patients with HIV Disease Little, Falace, Miller & Rhodus, Dental Management of the Medically Compromised Patient, 6 th Edition, Mosby-Year Book, Inc., 2002 (will get in 2 nd Year Student kit) Little, Falace, Miller & Rhodus, Dental Management of the Medically Compromised Patient, 6 th Edition, Mosby-Year Book, Inc., 2002 (will get in 2 nd Year Student kit)

37 The ODTP Process: Step 1 Radiographic Interpretation Patient has brought in an FMX dated 4/20/99. Do we need a new FMX?

38 The ODTP Process: Step 1 Radiographic Interpretation Complete a Radiographic Diagnosis Worksheet (available in Radiology)

39 The ODTP Process: Step 1 Radiographic Interpretation  Radiographic Findings:  #2: possible mesial caries  #3: gross distal caries w/ apical radiolucencies  #13, 24, 25: severe vertical bone loss  #14: gross mesial caries w/ apical radiolucencies  #4, 17, 30, 32: missing

40 The ODTP Process: Step 1 All of this should be done BEFORE your first appointment with Heather. The better prepared you are, the smoother and faster the appointment will go, and the better the impression you will make upon the patient.

41 The First Appointment: D0150 Initial Oral Examination Greet Heather in the waiting room and introduce yourself. Ask her how she is today. Does she have any tooth pain? Give her a brief overview of what you are going to do during this appointment.

42 The First Appointment: D0150 Initial Oral Examination Give her a brief overview of what you are going to do this appointment: “Today I’m going to do a very thorough examination of all of your teeth and gums, and then I’ll be able to discuss with you what dental care you need and what treatment options you have. I particularly want to evaluate your lower front teeth.”

43 The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs 1. Review the health history with the patient (MH) 2. Take vital signs (VS) 3. Perform intra- and extraoral exams (EOE & IOE) 4. Take diagnostic casts if needed

44 The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs Health History: Ask your questions from your Step 1 review of the completed form and record Heather’s responses to your questions on the Health History Interview Sheet.

45 The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs What is significant in Heather’s health history for safe delivery of dental treatment? Where do you record this information?

46 The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs Do you still have questions about Heather’s health? If so, how do you get them answered?

47 The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs Physical exam (PE) findings: VS: BP 105/70 – R, pulse 77 reg. EOE & IOE: all WNL

48 The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs This is a good time to start gathering a dental and social history of Heather. What questions do you want to ask?

49 Dental History: HCC: currently asymptomatic. DH: Last dental appt. for delivery of a maxillary partial denture, June Has had sporadic dental care most of her life. Perio: “deep cleanings” occasionally Ortho and Endo : none OS: #1,3,13,14,16 ext. at UOP in 1999; #4,19,30,32 ext. prior, different times Restorative: moderate restorations: amalgams, crowns, bridge #29 – 31, maxillary removable partial denture (RPD).

50 Social History: Grew up in Ireland, lived in Berlin, moved to Arizona in 1985, moved to LA in 1989, moved to SF in Parents deceased; 2 sisters, 1 brother living in Ireland. Separated from husband who lives in Arizona with their 19 y.o. son. Lives with 3 roommates in SF. Enjoys reading and furniture restoration.

51 The ODTP Process: Step 2 Medical History Interview/ Physical Exam/Vital Signs After completing Step 2, “present” your patient to the ODTP instructor before proceeding to any invasive examination, i.e. perio probing. Faculty will sign your paperwork and “grade” the steps in the computer.

52 The ODTP Process Use any waiting time during the ODTP appointment to take clinical photographs of Heather.  Basic patient intake photographs for chart record (7)  Full frontal face  Profile face  Full frontal teeth occluded  Right lateral teeth occluded  Left lateral teeth occluded  Full upper arch  Full lower arch  Additional images as needed for unique conditions or needs

53 The ODTP Process: Step 3 Periodontal Examination 1. Review x-rays, complete full mouth probing and comprehensive periodontal examination 2. Diagnose periodontal disease status 3. Plan periodontal treatment therapy 4. Plan follow-up/maintenance care

54 The ODTP Process: Step 3 Periodontal Examination Chart all findings in the computer and on the buff- colored Baseline Clinical Examination form

55 The ODTP Process: Step 3 Periodontal Examination Periodontal Findings: Recession: generalized 2 – 4 mm w/ 8 mm #25 facial Pockets: generalized 3 – 4 mm w/ localized 5 – 7 mm Plaque index: 1 – 2 Mobilities: #23 – 25 Class 2, severe vertical bone loss Furcations: Class I & II on all remaining molars, Class I on #5 & 12

56 The ODTP Process: Step 3 Periodontal Examination What is your periodontal diagnosis? Does Heather have active or stabilized disease? Since we have x-rays from 1999 and now from 2005, we can compare bone levels, furcas, and defects.

57 The ODTP Process: Step 3 Periodontal Examination What is your periodontal diagnosis? Generalized moderate chronic periodontitis with localized severe chronic periodontitis What is the etiology? Moderate generalized bacterial plaque and calculus; heavy smoker and moderate alcohol intake.

58 The ODTP Process: Step 3 Periodontal Examination What is Heather’s prognosis? Generally fair as is, good if she quits smoking and improves her oral hygiene; prognosis poor for 23 – 25. Treatment plan: 4 quads root planing, ITE, recall interval to be determined.

59 The ODTP Process: Step 4 Oral Hygiene Instruction Full instruction customized to your patient’s individual needs. After completing Steps 3 and 4, “present” your patient to the Perio instructor. Faculty will sign your paperwork and “grade” the steps in the computer.

60 The ODTP Process: Step 5 Dental & Occlusal Exam/ Problem Listing 1. Charting of restorations, caries, pathology 2. Ortho/occlusion screening 3. Caries risk assessment 4. List all findings and tentative solutions

61 The ODTP Process: Step 5 Dental & Occlusal Exam/ Problem Listing 1. Charting of restorations, caries, pathology: in the computer 2. Ortho/occlusion screening: in the computer and on Orthodontic Screening form

62 The ODTP Process: Step 5 Dental & Occlusal Exam/ Problem Listing 3. Caries risk assessment: on Caries Risk Assessment form. What is the patient’s risk level and how will we, the patient and you together, manage their caries risk level?

63 The ODTP Process: Step 5 Dental & Occlusal Exam/ Problem Listing 4. List all hard tissue findings and tentative solutions: on ODTP Dental Examination Worksheet in detail. List all restorations: if no problem, write WNL; if problem, describe exactly what it is and where.

64 The ODTP Process: Step 5 Dental & Occlusal Exam View of Heather’s maxillary arch:

65 The ODTP Process: Step 5 Dental & Occlusal Exam View of Heather’s mandibular arch:

66 The ODTP Process: Step 5 Dental & Occlusal Exam Anterior view of Heather’s dentition:

67 The ODTP Process: Step 5 Dental & Occlusal Exam View of Heather’s right lateral side:

68 The ODTP Process: Step 5 Dental & Occlusal Exam View of Heather’s left lateral side:

69 The ODTP Process: Step 5 Dental & Occlusal Exam Clinical Findings: #1,3,4,13,14,16,17,19,30,32: missing #2: MO amalgam with mesial recurrent caries at ginigival margin #5: MOD amalgam – WNL #12: PFM crown – WNL #15: FVC crown – WNL #18: PFM crown – WNL #21: DO amalgam – WNL #23, 24, & 25: guarded/poor perio prognosis #28: DO amalgam – WNL #29 – 31: FVC 3-unit bridge – WNL

70 The ODTP Process: Step 6 Tentative Treatment Plan 1. Determine the ideal treatment options for the various dental problems found. 2. Determine appropriate alternative treatment choices for the dental problems found. 3. Discuss treatment goals with the patient.

71 The ODTP Process: Step 6 Tentative Treatment Plan In Heather’s case, her dental problems are: 1. Moderate generalized periodontitis disease with localized severe disease 2. Caries on the Mesial of #2 3. Severe bone loss & mobility #23, 24, & 25 What treatment options does she have?

72 The ODTP Process: Step 6 Tentative Treatment Plan Moderate to severe periodontitis Moderate to severe periodontitis What treatment options does she have? 1. 4 quadrants of root planing 2. No treatment What are the risks, benefits, and alternatives (RBAs) of each option?

73 The ODTP Process: Step 6 Tentative Treatment Plan Caries on the Mesial of #2 Caries on the Mesial of #2 What treatment options does she have? 1. M or MOL amalgam 2. Full veneer crown (FVC) 3. No treatment What are the risks, benefits, and alternatives (RBAs) of each option?

74 The ODTP Process: Step 6 Tentative Treatment Plan Severe bone loss & mobility #23 – 25 Severe bone loss & mobility #23 – 25 What treatment options does she have? 1. Re-evaluate following perio therapy 2. Extract and replace teeth with…? 3. No treatment What are the risks, benefits, and alternatives (RBAs) of each option?

75 The ODTP Process: Step 6 Tentative Treatment Plan After completing your hard tissue examination and formulating a tentative treatment plan, “present” your patient to the ODTP instructor. Discuss findings and treatment options with the instructor and the patient.

76 The ODTP Process: Step 6 Tentative Treatment Plan After “presenting”, reviewing, and discussing your findings and treatment options with the ODTP instructor and your patient, The ODTP instructor will decide if specialist consultations are needed.

77 The ODTP Process: Step 6 Tentative Treatment Plan After completing your hard tissue examination and formulating a tentative treatment plan with your patient and the ODTP instructor, The faculty will sign your paperwork and “grade” the steps in the computer.

78 The ODTP Process: Step 7 Treatment Prioritizing/Contract 1. Prioritize and finalize the treatment plan with the patient and review it with the ODTP instructor. 2. Enter the treatment into the computer in prioritized sequence, print it out and have the patient sign the printout. 3. Have the ODTP instructor clinically approve your treatment plan in the computer.

79 The ODTP Process: Step 7 Treatment Prioritizing/Contract For Heather’s case, the priorities are: 1. 4 quadrants of root planing 2. M amalgam on #2 3. Re-evaluate perio health for status of #24 & 25. Are these teeth salvageable? If not, what replacement options does she have?

80 The ODTP Process: The Final Step At the completion of your appointment, or during “down” times during the appointment, Write up your treatment record.

81 Treatment Records The quantity of information gathered from the comprehensive patient examination process can be overwhelming. The quantity of information gathered from the comprehensive patient examination process can be overwhelming. It is therefore essential to have a systematic method for recording and organizing all of the data. It is therefore essential to have a systematic method for recording and organizing all of the data.

82 Treatment Records Paperwork can be viewed as a burden, but it is also a necessary fact of life in every practice. Paperwork can be viewed as a burden, but it is also a necessary fact of life in every practice. Just do it, and get used to it! (It’s only going to get worse!) Just do it, and get used to it! (It’s only going to get worse!) Learn how to make the paperwork serve your needs. Learn how to make the paperwork serve your needs. “The palest ink is stronger than the best memory.” “The palest ink is stronger than the best memory.”

83 Treatment Records The treatment record is perhaps the single most important document in the patient chart. The treatment record is perhaps the single most important document in the patient chart. It is essential that every aspect of patient care be fully documented. It is essential that every aspect of patient care be fully documented. “If it isn’t written down, it didn’t happen.” “If it isn’t written down, it didn’t happen.”

84 Treatment Records “The complete record contains a description of the patient’s original condition, your diagnosis and treatment plan, progress notes on the treatment performed and the results of that treatment. It should also contain the patient’s personal data, health history information, and informed consent documentation. The record should be organized logically and in language that is comprehensible to all who use it.” “The complete record contains a description of the patient’s original condition, your diagnosis and treatment plan, progress notes on the treatment performed and the results of that treatment. It should also contain the patient’s personal data, health history information, and informed consent documentation. The record should be organized logically and in language that is comprehensible to all who use it.” (Dentist’s Guide to Keeping Patient Records: Strategies & Solutions, California Dental Association, 1996) (Dentist’s Guide to Keeping Patient Records: Strategies & Solutions, California Dental Association, 1996)

85 Treatment Records The patient treatment record is perhaps the single most important document in the patient chart. It forms a running narrative of the diagnostic process, the treatment plan derivation, the delivery of care, care outcomes, and the patient’s involvement in care. The patient treatment record is perhaps the single most important document in the patient chart. It forms a running narrative of the diagnostic process, the treatment plan derivation, the delivery of care, care outcomes, and the patient’s involvement in care. This ongoing record is the practicing dentist’s first reference at every subsequent patient visit. This ongoing record is the practicing dentist’s first reference at every subsequent patient visit.

86 Treatment Records “The patient record not only serves as the history of the therapeutic and business relationship between dentist and patient, but also it is the most reliable – and most relied upon – defense against a malpractice allegation. Malpractice allegations remain subjective until they can be substantiated, and sound records are an objective and factual measure of the actual treatment provided.” “The patient record not only serves as the history of the therapeutic and business relationship between dentist and patient, but also it is the most reliable – and most relied upon – defense against a malpractice allegation. Malpractice allegations remain subjective until they can be substantiated, and sound records are an objective and factual measure of the actual treatment provided.” (Liability Lifeline, TDIC, California Dental Association, 1994)

87 Treatment Records The patient treatment record is perhaps the single most important document in the patient chart. It forms a running narrative of the diagnostic process, the treatment plan derivation, the delivery of care, care outcomes, and the patient’s involvement in care. The patient treatment record is perhaps the single most important document in the patient chart. It forms a running narrative of the diagnostic process, the treatment plan derivation, the delivery of care, care outcomes, and the patient’s involvement in care. From a legal standpoint the patient treatment record has the greatest credibility, and when properly filled out, offers the best defense against litigation. From a legal standpoint the patient treatment record has the greatest credibility, and when properly filled out, offers the best defense against litigation.

88 Treatment Records Document all treatment visits by chronological order, what services were performed, details of the procedures including what materials were used, and note any complications. Document all treatment visits by chronological order, what services were performed, details of the procedures including what materials were used, and note any complications. Document all instructions, referrals, and recommendations given to the patient with notation of all RBAs discussed. Document all instructions, referrals, and recommendations given to the patient with notation of all RBAs discussed.

89 Treatment Records Document the informed consent process and any significant questions and comments made by the patient. Document the informed consent process and any significant questions and comments made by the patient. Document all patient contacts: appointments, telephone calls, letters, etc. Document all patient contacts: appointments, telephone calls, letters, etc. Document all failed and cancelled appointments, late arrivals, etc. Document all failed and cancelled appointments, late arrivals, etc.

90 Treatment Records Ten rules for complete patient records: Ten rules for complete patient records: 1. Use a consistent style and standard abbreviations for all entries to foster your professionalism, and thereby your credibility. 2. Use blue or black ink only – colors do not copy well, and pencil smears and fades over time and can be too easily altered, reducing the credibility of your records.

91 Treatment Records Ten rules for complete patient records: Ten rules for complete patient records: 3. Use a single line to cross out errors. 4. Do not use whiteout – not only is it messy, but it may be construed as an effort to conceal information. 5. Date and explain any corrections, making corrections as they happen with the true date of the correction entry.

92 Treatment Records Ten rules for complete patient records: Ten rules for complete patient records: 6. Write legibly – an illegible record can lead to inappropriate guesswork and suggests a careless, disorganized attitude. 7. Note discussions of treatment options including the risks, benefits, and alternatives (RBAs) – list all options discussed. A handy abbreviation: DWP = discussed with patient A handy abbreviation: DWP = discussed with patient

93 Treatment Records Ten rules for complete patient records: Ten rules for complete patient records: 8. Express your honest concerns about patient needs – this reflects an understanding of the patient’s needs and documents that the dentist listened to, noted, and possibly addressed the patient’s expressed needs. 9. Record missed appointments and failure to follow instructions, and record your attempts to educate and change patient behavior. This information can be vital for documenting your due diligence in caring for the patient.

94 Treatment Records Ten rules for complete patient records: Ten rules for complete patient records: 10. Never write derogatory remarks in the record – this does not mean you should not record negative information, such as a patient’s failure to follow treatment advice, but record all remarks in a dispassionate and objective manner. Adapted from the June/July 1995 New York State Dental Journal

95 Treatment Records The SOAP note entry format The SOAP note entry format A clear, concise, and standardized form for recording all patient information and treatment A clear, concise, and standardized form for recording all patient information and treatment Forms the basis for analyzing all patient data including treatment outcomes Forms the basis for analyzing all patient data including treatment outcomes Is a universal format for discussing your patient with physicians or specialty practitioners, and for case reports in the dental/medical literature Is a universal format for discussing your patient with physicians or specialty practitioners, and for case reports in the dental/medical literature

96 Treatment Records The SOAP note entry format The SOAP note entry format S = Subjective O = Objective A = Assessment P = Plan/Procedure

97 Treatment Records The SOAP note entry format The SOAP note entry format S = Subjective What does the patient tell you? Includes CC = Chief Concern CC = Chief Concern HCC = History of Chief Concern HCC = History of Chief Concern MH = Medical History MH = Medical History DH = Dental History DH = Dental History SH = Social History SH = Social History

98 Treatment Records The SOAP note entry format The SOAP note entry format O = Objective What are your observations? Includes PE/VS = Physical Exam & Vital Signs PE/VS = Physical Exam & Vital Signs EOE & IOE = Extra- & Intraoral Exams EOE & IOE = Extra- & Intraoral Exams Summary of appearance of both soft and hard tissues Summary of appearance of both soft and hard tissues RE = Radiographic Exam RE = Radiographic Exam

99 Treatment Records The SOAP note entry format The SOAP note entry format A = Assessment What is your diagnosis? Includes Periodontal diagnosis Periodontal diagnosis Caries risk assessment Caries risk assessment Restorative diagnosis Restorative diagnosis Addresses patient’s chief concern Addresses patient’s chief concern

100 Treatment Records The SOAP note entry format The SOAP note entry format P = Plan/Procedure What treatment did you or will you provide? Includes complete notes on Treatment plan discussion Treatment plan discussion Procedures done or planned Procedures done or planned Instructions, recommendations, referrals Instructions, recommendations, referrals Prescriptions Prescriptions DWP: RBAs DWP: RBAs

101 The Treatment Record: S.O.A.P. Notes For ALL procedures: First line: the date and procedure code and description

102 The Treatment Record: S.O.A.P. Notes For ODTP we use an extended SOAP note: 10/3/05 D0150 Initial oral exam (S: Subjective) 1. ID: Patient age, sex, etc. 2. CC: Chief Concern 3. HCC: History of Chief Concern 4. MH: Medical History 5. DH: Dental History 6. SH: Social History

103 The Treatment Record: S.O.A.P. Notes For ODTP we use an extended SOAP note: (O: Objective) 7. PE: Physical Exam (VS, EOE, IOE, TMJ) 8. Perio Dx: Periodontal Exam findings 9. RE: Radiographic Exam findings 10. Hard Tissue Exam findings

104 The Treatment Record: S.O.A.P. Notes For ODTP we use an extended SOAP note: (A: Assessment) 11. Periodontal Diagnosis 12. Hard Tissue “Diagnosis” 13. Caries Risk Assessment Make sure the patient’s CC is addressed!

105 The Treatment Record: S.O.A.P. Notes For ODTP we use an extended SOAP note: (P: Plan/Procedure) Includes complete notes on 14. DWP: Treatment plan discussion: RBAs – options and decisions 15. Treatment plan or procedures done 16. Instructions, recommendations, referrals, prescriptions 17. NA or NV: Next Appointment or Visit

106 The Treatment Record: S.O.A.P. Notes For restorative appts., etc., use abbreviated SOAP note: (P: Plan/Procedure) Treatment progress notes include:  Tooth/region and procedure  Type, dose, location of anesthetics  Isolation technique  All materials and medications used  Shade, occlusion, lab prescription  Post-operative instructions given  Treatment outcomes

107 Treatment Records Patient privacy (HIPPA) Patient privacy (HIPPA) Patient privacy must be respected at all times Patient privacy must be respected at all times Charts must be regarded as confidential, privileged information Charts must be regarded as confidential, privileged information Patient’s have entrusted their personal information to us Patient’s have entrusted their personal information to us We, as doctors, are privileged to have access to this confidential patient information We, as doctors, are privileged to have access to this confidential patient information Therefore, we must make every effort to preserve chart, and thereby patient, confidentiality at all times Therefore, we must make every effort to preserve chart, and thereby patient, confidentiality at all times

108 Patient Presentation A derivative of the SOAP note format A derivative of the SOAP note format The presentation should be a brief summation of significant findings and history. The presentation should be a brief summation of significant findings and history. The SOAP note format helps practitioners to organize their thoughts The SOAP note format helps practitioners to organize their thoughts Analyze patient data Analyze patient data Frame in an standard sequence Frame in an standard sequence

109 Patient Presentation Example: Example: Mary is a 42 y.o. African-American female with a chief concern to have her teeth cleaned and bleached. She has a medical history significant for hypertension controlled with the beta-adrenergic blocker Propanolol and for use of the antidepressant medication Zoloft. Mary is a 42 y.o. African-American female with a chief concern to have her teeth cleaned and bleached. She has a medical history significant for hypertension controlled with the beta-adrenergic blocker Propanolol and for use of the antidepressant medication Zoloft. Her initial oral exam was completed Sept. 1, 2005 and her perio treatment of 4 quadrants of root planing was completed on Sept. 15 th. Her hypertension is controlled today with blood pressure measured at 134/88 on her right arm, and a strong, regular pulse of 72. Her initial oral exam was completed Sept. 1, 2005 and her perio treatment of 4 quadrants of root planing was completed on Sept. 15 th. Her hypertension is controlled today with blood pressure measured at 134/88 on her right arm, and a strong, regular pulse of 72. Tooth #12 has a distal carious lesion with a good restorative prognosis. Tooth #12 has a distal carious lesion with a good restorative prognosis. Today I’m treating #12 with a DO amalgam. I will minimize the use of vasoconstrictor containing local anesthetic in this patient due to the use of non-specific beta-blocker and CNS depressant medications. Today I’m treating #12 with a DO amalgam. I will minimize the use of vasoconstrictor containing local anesthetic in this patient due to the use of non-specific beta-blocker and CNS depressant medications. S O A P

110 The ODTP Process: Points to remember: Yes, the ODTP process is time consuming. Yes, the ODTP process is time consuming. A well done examination and treatment plan are the key to successful patient care. A well done examination and treatment plan are the key to successful patient care.

111 The ODTP Process: Points to remember: The ODTP appointment is an excellent time to build patient rapport. The ODTP appointment is an excellent time to build patient rapport. The better prepared you are, the smoother and faster the appointment will go, and the better the impression you will have upon the patient. The better prepared you are, the smoother and faster the appointment will go, and the better the impression you will have upon the patient.

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