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D4346 - Periodontal Re-Eval [Carious Legion Clinic Help]

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periodontics:4346_re-eval

D4346 - Periodontal Re-Eval

This is from the perio clinic manual. It needs to be improved upon

  • Patient Education
    • Review purpose of visit.
    • Set patient expectations for appointment.
  • Update medical history.
  • Update vital signs, if indicated.
  • Do NOT disclose plaque until faculty member has examined patient.
  • Estimate plaque control when probing sulci.
  • Complete periodontal examination and document findings.
    • Probe and record all areas.
    • Write thorough gingival description.
    • Write accurate diagnosis based on current findings.
    • Record recommendations for further treatment, eg. :
      • continued S/RP (if this is your recommendation, C-code the 4346, notify faculty, and continue scaling & root planing under a new 4346 code kept in “I” 4-6 weeks after treatment).
      • surgery (if this is your recommendation, obtain a consultation with a perio resident, if possible).
      • maintenance
      • compromised maintenance
  • Complete documentation of findings.
  • Notify faculty member that you would like to present patient findings for reevaluation of initial therapy.
  • Present patient synopsis to faculty member.
  • Discuss findings.
  • Ask any questions.
  • Faculty member will examine patient, discuss findings, & approve or sign:
    • periodontal exam sheet in record
    • progress notes
    • performance evaluation sheet (following your self-evaluation)
  • Polish all teeth unless polishing is contraindicated.
  • Use dental floss interproximally.
  • Apply topical fluoride if indicated.
  • Perform patient Education
    • Discuss recommendations for further treatment
      • Rationale.
      • Patient expectations.
    • For patients being placed in the maintenance phase:
      • Purpose and importance of periodontal maintenance.
      • Recommended maintenance interval.
    • Procedure for scheduling maintenance.
  • If additional treatment (surgery) is indicated:
    • Before consult with perio resident:
      • Make study casts and have proper documentation for referral (green referral sheet from grad perio area).
      • Have current radiographs, if unsure, check with resident.
    • After perio consult with resident:
    • Change treatment plan with OD faculty member.
    • Have it signed by patient, faculty member, financial services and PCC.
    • Make appointment with periodontal chief surgical assistant (take patient record and addition to treatment plan form with you).

Sample Progress Note

Periodontal reevaluation complete. Periodontal health.
Pt. assigned to periodontal maintenance. NV: perio maintenance.


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periodontics/4346_re-eval.txt · Last modified: 2013/06/20 22:12 by brent