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Oral Diagnosis

Initial Comprehensive Oral Exam (D0150)

  1. Before the appointment, it is preferred that you do a radiograph interpretation on the patient's screening X-rays. You will not be able to progress past the odontogram (step 11) without finishing this stage! You should also review the screening form to get an idea of the patient's history.
  2. Check patient's screening records and fill as much as you can in the 'Patient Check-In Form'.
  3. Seat patient. Ask them if they are in pain and reason for the visit (CC). Ask them about form-relevant topics and fill this into the check-in form (health history/A.A.C.D.I.S?/medications/smoker/alcohol/allergies).
  4. Take vitals and record this on the Axium form Vital Signs (add form if not present).
  5. Check in with OD faculty or, preferably, your group leader.
  6. Code (planned codes!) 150, 150.1, 150.2, 2400, 100 & 190 (unless patient is edentulous), and 0046.
  7. Open a new Health History form and fill out the form with the patient. Be sure to answer both the Medical Hx and Dental Hx tabs.
  8. If the patient is on any medications, open a new Medication History form and fill this out with the patient. Use Lexicomp to fill in more detailed information about each drug. OPTIONAL: It is useful to have the patient obtain a record of their dispensed /prescribed drugs from their pharmacist and bring this to the initial OD appointment.
  9. Stop at this point and check-in with faculty.
  10. Open a new Head and Neck Findings form. Perform an extraoral exam on the patient and record any positive findings.
  11. Open a new Intraoral Findings form. Perform an intraoral on the patient and record any positive findings.
  12. Add information about each tooth (existing conditions and materials) to the odontogram. Utilize both clinical and radiographic findings. This can be done by clicking the Tx History tab, clicking the folder with the plus sign, and searching Dental Conditions or Dental Materials. This stage cannot be approved without previously finishing and radiograph interpretation!
  13. Open a new Caries Risk Assessment form and fill this out with the patient. Do not forget to fill all the tabs (the caries monitoring tab is usually not filled out).
  14. At this point, evaluate if you have time to complete probing stage (100 and 190). If time is not available, schedule patient with PCC, checkout patient at finance, dismiss patient, then write note. Utilize time between next appointment to work on sections of the Tx Plan that you have information for (objectives, problems, diagnosis, etc.).
  15. Sign in on the Perio pink sheet indicating you are starting perio charting and analysis for your patient.
  16. Open Perio tab and create a new Perio Probing chart. Probe the patient and record probing depths, free gingival margin depth, and BOP. Make sure your attachment loss numbers (PD - FGM = AL) are especially correct for deep PD areas. Confirm these findings with your radiographs (it should make sense).
  17. Open a new Periodontal Analysis form. Complete this form through a comprehensive examination of the gingival tissue and surrounding tooth structure.
  18. Sign blue form indicating you wish to go over findings/charting with OD perio faculty. Confirm results with perio faculty and have all perio-related forms/findings approved before continuing.
  19. Write the Diagnostic Study. Write the 'tentative' treatment plan (150.1; hopefully you've pre-filled most of this to speed up the process). If consults are required, have these planned and done (Prosthodontics/Periodontics/Endodontics/TMD).
  20. Confirm treatment plan with faculty, and take patient to front to sign-off definitive treatment plan (150.2).
  21. Optional/Recommended: If indicated (important for OD Seminar), take alginate impressions of maxillary and mandibular arches, as well as a facebow. Confirm impressions are clinically acceptable with faculty and save these to pour diagnostic casts (pour casts after dismissing patient).
  22. Write your note. Confirm all forms, treatment plan, perio, and findings have been approved. Take patient to PCC or schedule patient (apt. slip) for next visit. Take patient to finance to check-out. Dismiss patient.

Following above is being refined.

2013/06/12 22:22

Periodic Oral Exam/POE (D0120)

Note: Before you do your POE, you must have up-to-date perio readings. This means that if perio maintenance is overdue, you must do this before your POE!

  1. Check patient's records and fill 'Patient Check-In Form'.
  2. Seat patient. Ask them if they are in pain and if there are any changes in their health history or medications. Take vitals and record this on Axium.
  3. Check in with OD faculty or, preferably, your group leader.
  4. Review the most recent health history form. You will ask the patient each question again, and only update answers which have changed. You can do this by either clicking a different answer or selecting the answer and pressing Ctrl+R.
  5. Review Dental History and adjust answers as necessary.
  6. Review Tobacco Assessment form and adjust answers as necessary.
  7. Review Medication History form and adjust answers as necessary.
  8. Open a new Caries Risk Assessment form and fill this out with the patient.
  9. Perform an extraoral exam and update findings (or adjust findings) on most recent Head and Neck form.
  10. Perform an intraoral exam and update findings (or adjust findings) on most recent Intraoral form.
  11. Update Odontogram. Remove findings no-longer present (if faculty requests), and add new findings.
  12. Ask faculty you checked-in with to verify findings. Afterwards, ask faculty if bitewings are needed.
  13. If there is remaining time to do a treatment plan, do so. If not, schedule patient's next appointment (slip to PCC, or walk patient to PCC), then check-out and dismiss patient.
  14. Have what is complete approved by faculty (if not done so already), and write a note:

D0120 and D2400

Patient presented for POE. Patient arrived on time. Vitals were taken: 120/80 mmHg RASit, 60 bpm S&R. Health history, dental history, extraoral and intraoral exams were updated. Caries risk assessment was completed. Odontogram was updated. Bitewings were taken.

NV: Tx Planning

2013/06/12 22:23

Samples for Objective List in Treatment Plan

  1. Establish and maintain periodontal health and oral hygiene
  2. Control caries activity
  3. Restore carious teeth
  4. Establish function, esthetics and occlusion
2013/06/12 22:51
oral_diagnosis.txt · Last modified: 2013/06/12 22:49 by brent