Transcript THE ODTP PROCESS

THE ODTP
PROCESS
A Case-Based Overview
Orientation to the Clinical Practice of General
Dentistry, Fall Quarter
Alan W. Budenz, MS, DDS, MBA
Heather – a new patient


Screened by faculty September 26, 2005
Designated as a 2nd Year teaching case
Chief Concern (CC):
I would like a bridge for my lower
front teeth
The ODTP Process: Step 1
Preparation

Pre-appointment preparation

Review chart
Read screening and/or treatment notes
 Review health history
 Review radiographs



Make notes
Plan out the first appointment
The Pacific
Health History
Questionnaire
Form
- Comprehensive
- Standardized
- Translations
The Pacific Health History
Questionnaire Form

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.
The Pacific Health History
Questionnaire Form

Section 2: Signs and Symptoms
 Focuses on various signs and symptoms that
are indicative of medical problems.
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.

The Pacific Health History
Questionnaire Form

Section 2: Signs and 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.
The Pacific Health History
Questionnaire Form

Section 3: Specific Diseases
 Concentrates on specific diseases which have
been previously diagnosed by a physician.
 All of these diseases have a systemic effect.
 Therefore, all of these diseases have
potential ramifications on dental care
delivery.
The Pacific Health History
Questionnaire Form

Section 3: Specific Diseases
 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.
The Pacific Health History
Questionnaire Form

Section 4: Treatments
 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.
The Pacific Health History
Questionnaire Form

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.
 Documents the extent of any problems noted
on other parts of the health history, or
possibly problems not identified by the
patient.
The Pacific Health History
Questionnaire Form

Section 6: Women Only
 Elicits specific information relative to women
uniquely.
 Pregnancy and the use of birth control pills
are especially pertinent to dental care
delivery.
The Pacific Health History
Questionnaire Form

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.
The Pacific Health History
Questionnaire Form



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.
At start of each appointment, ask “Have there
been any changes in your health?”
Note response in the treatment record.
The Health History Form


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



To insure that the patient properly understood
the questions
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.
The Pacific
Health
History
Interview
Sheet
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.
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 Pacific Health History Interview
Form

Includes 6 questions that need to be
verbally asked of every patient:
Do you have any…






Cardiovascular problems?
Infectious diseases?
Allergies to medicines (or latex)?
Bleeding problems?
Take any medications?
Other medical problems not asked about?
The Pacific Health History Interview
Form






Cardiovascular
problems?
Infectious diseases?
Allergies to medicines
(or latex)?
Bleeding problems?
Take any medications?
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.
The Pacific Health History Interview
Form

Cardiovascular problems?




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)
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.
Most specifically, patients should be
asked if they have any history of “heart
problems or heart murmurs”.

If “yes”, questions to ask:




When was the problem first diagnosed?
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?
For heart murmurs specifically: Was it termed
functional or organic? Is there regurgitation?
The Pacific Health History Interview
Form

Infectious diseases?



Hepatitis is the most common infectious
disease with implications for dental
complications.
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...
The Pacific Health History Interview
Form

Infectious diseases?

The one exception...
Active tuberculosis requires additional
precautions, and these patients should
generally be treated only in a hospital
isolation facility.
The Pacific Health History Interview
Form

Allergies to medicines (or latex)?

Patients should be asked about allergies to
any medications in general, and specifically
about possible allergies to:
Antibiotics
 Pain medications, including aspirin
 Narcotics
 Local anesthetics
 Latex

The Pacific Health History Interview
Form

Hematologic, bleeding problems?



Has the patient ever had any bleeding
problems or do they bruise easily?
Positive responses may be indicative of
undiagnosed hematologic disease.
Referral to or consultation with the patient’s
physician may be indicated.
The Pacific Health History Interview
Form

Take any medications?


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.
The Pacific Health History Interview
Form

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.
Patients often fail to disclose these medications
unless specifically asked about them.
The Pacific Health History Interview
Form

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.
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.
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?
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?
The ODTP Process:
Step 1
Medical History Review
“Yes” answers to
#37: Stomach problems, ulcer
What questions do you want to ask?
The ODTP Process:
Step 1
Medical History Review
“Yes” answers to
#62: Taking medications
Listed: Warfarin, Prevacid
What questions do you want to ask?
The ODTP Process:
Step 1
Medical History Review
“Yes” answers to
#63: Tobacco
What questions do you want to ask?
Health History Review

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?
Dental Management of Medically
Complex Patients

Good sources for information on this
subject:

From the UOP web site: www.dental.pacific.edu
Protocols for the Dental Management of Medically
Complex Patients
 Protocols for the Dental Management of Patients with
HIV Disease


Little, Falace, Miller & Rhodus, Dental
Management of the Medically Compromised
Patient, 6th Edition, Mosby-Year Book, Inc., 2002
(will get in 2nd Year Student kit)
The ODTP Process:
Step 1
Radiographic Interpretation
Patient has brought in an FMX dated
4/20/99. Do we need a new FMX?
The ODTP Process:
Step 1
Radiographic Interpretation
Complete a
Radiographic Diagnosis
Worksheet (available
in Radiology)
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
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.
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.
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.”
The ODTP Process:
Step 2
Medical History Interview/
Physical Exam/Vital Signs
1.
2.
3.
4.
Review the health history with the patient
(MH)
Take vital signs (VS)
Perform intra- and extraoral exams
(EOE & IOE)
Take diagnostic casts if needed
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.
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?
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?
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
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?
Dental History:
HCC: currently asymptomatic.
DH: Last dental appt. for delivery of a maxillary
partial denture, June 2000.
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).
Social History:
Grew up in Ireland, lived in Berlin,
moved to Arizona in 1985, moved to
LA in 1989, moved to SF in 1998.
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.
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.
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
The ODTP Process:
Step 3
Periodontal Examination
1.
2.
3.
4.
Review x-rays, complete full mouth
probing and comprehensive periodontal
examination
Diagnose periodontal disease status
Plan periodontal treatment therapy
Plan follow-up/maintenance care
The ODTP Process:
Step 3
Periodontal Examination
Chart all findings in
the computer and
on the buffcolored Baseline
Clinical
Examination form
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
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.
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.
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.
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.
The ODTP Process:
Step 5
Dental & Occlusal Exam/
Problem Listing
1.
2.
3.
4.
Charting of restorations, caries, pathology
Ortho/occlusion screening
Caries risk assessment
List all findings and tentative solutions
The ODTP Process:
Step 5
Dental & Occlusal Exam/
Problem Listing
1.
2.
Charting of restorations, caries, pathology:
in the computer
Ortho/occlusion screening: in the computer
and on Orthodontic Screening form
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?
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.
The ODTP Process:
Step 5
Dental & Occlusal Exam
View of Heather’s maxillary arch:
The ODTP Process:
Step 5
Dental & Occlusal Exam
View of Heather’s mandibular arch:
The ODTP Process:
Step 5
Dental & Occlusal Exam
Anterior view of Heather’s dentition:
The ODTP Process:
Step 5
Dental & Occlusal Exam
View of Heather’s right lateral side:
The ODTP Process:
Step 5
Dental & Occlusal Exam
View of Heather’s left lateral side:
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
The ODTP Process:
Step 6
Tentative Treatment Plan
1.
2.
3.
Determine the ideal treatment options
for the various dental problems found.
Determine appropriate alternative
treatment choices for the dental
problems found.
Discuss treatment goals with the
patient.
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?
The ODTP Process:
Step 6
Tentative Treatment Plan
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?
•
The ODTP Process:
Step 6
Tentative Treatment Plan
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?
•
The ODTP Process:
Step 6
Tentative Treatment Plan
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?
•
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.
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.
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.
The ODTP Process:
Step 7
Treatment Prioritizing/Contract
1.
2.
3.
Prioritize and finalize the treatment plan
with the patient and review it with the
ODTP instructor.
Enter the treatment into the computer in
prioritized sequence, print it out and have
the patient sign the printout.
Have the ODTP instructor clinically approve
your treatment plan in the computer.
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?
The ODTP Process:
The Final Step
At the completion of your appointment, or
during “down” times during the
appointment,
Write up your treatment record.
Treatment Records


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.
Treatment Records


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!)

Learn how to make the paperwork serve
your needs.
“The palest ink is stronger than the best memory.”
Treatment Records


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.
“If it isn’t written down, it didn’t happen.”
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.”
(Dentist’s Guide to Keeping Patient Records: Strategies & Solutions,
California Dental Association, 1996)
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.
This ongoing record is the practicing
dentist’s first reference at every
subsequent patient visit.
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.”
(Liability Lifeline, TDIC, California Dental Association, 1994)
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.
From a legal standpoint the patient
treatment record has the greatest
credibility, and when properly filled out,
offers the best defense against litigation.
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 instructions, referrals, and
recommendations given to the patient
with notation of all RBAs discussed.
Treatment Records



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 failed and cancelled
appointments, late arrivals, etc.
Treatment Records

1.
2.
Ten rules for complete patient records:
Use a consistent style and standard
abbreviations for all entries to foster your
professionalism, and thereby your credibility.
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.
Treatment Records

Ten rules for complete patient records:
3.
Use a single line to cross out errors.
4.
5.
Do not use whiteout – not only is it messy, but
it may be construed as an effort to conceal
information.
Date and explain any corrections, making
corrections as they happen with the true date
of the correction entry.
Treatment Records

6.
7.
Ten rules for complete patient records:
Write legibly – an illegible record can lead to
inappropriate guesswork and suggests a
careless, disorganized attitude.
Note discussions of treatment options including
the risks, benefits, and alternatives (RBAs) –
list all options discussed.
A handy abbreviation: DWP = discussed with patient
Treatment Records

8.
9.
Ten rules for complete patient records:
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.
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.
Treatment Records

10.
Ten rules for complete patient records:
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
Treatment Records

The SOAP note entry format



A clear, concise, and standardized form for
recording all patient information and
treatment
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
Treatment Records

The SOAP note entry format
S = Subjective
O = Objective
A = Assessment
P = Plan/Procedure
Treatment Records

The SOAP note entry format
S = Subjective
What does the patient tell you?
Includes





CC = Chief Concern
HCC = History of Chief Concern
MH = Medical History
DH = Dental History
SH = Social History
Treatment Records

The SOAP note entry format
O = Objective
What are your observations?
Includes




PE/VS = Physical Exam & Vital Signs
EOE & IOE = Extra- & Intraoral Exams
Summary of appearance of both soft and
hard tissues
RE = Radiographic Exam
Treatment Records

The SOAP note entry format
A = Assessment
What is your diagnosis?
Includes




Periodontal diagnosis
Caries risk assessment
Restorative diagnosis
Addresses patient’s chief concern
Treatment Records

The SOAP note entry format
P = Plan/Procedure
What treatment did you or will
you provide?
Includes complete notes on





Treatment plan discussion
Procedures done or planned
Instructions, recommendations, referrals
Prescriptions
DWP: RBAs
The Treatment Record:
S.O.A.P. Notes
For ALL procedures:
First line: the date and procedure code and
description
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
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
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!
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
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
Treatment Records

Patient privacy (HIPPA)


Patient privacy must be respected at all
times
Charts must be regarded as confidential,
privileged information



Patient’s have entrusted their personal
information to us
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
Patient Presentation

A derivative of the SOAP note
format


The presentation should be a brief
summation of significant findings and
history.
The SOAP note format helps
practitioners to organize their thoughts


Analyze patient data
Frame in an standard sequence
Patient Presentation

S
O
A
P
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.

Her initial oral exam was completed Sept. 1, 2005 and
her perio treatment of 4 quadrants of root planing was
completed on Sept. 15th. 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.

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.
The ODTP Process:
Points to remember:
•Yes, the ODTP process is time
consuming.
•A
well done examination and
treatment plan are the key to
successful patient care.
The ODTP Process:
Points to remember:
•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.
Unless…