PROGRESS NOTES
ORAL
DIAGNOSIS
• INITIAL ORAL EXAM / COMPREHENSIVE ORAL EXAM
– RECORDING OF MED & DENT HISTORY
– GENERAL HEALTH ASSESSMENT
– INTRA AND EXTRAORAL HARD & SOFT TISSUES
– EVALUATION » CARIES, MISSING AND UNERUPTED TEETH, RESTORATIONS » PERIODONTAL CONDITIONS INCLUDING PERIO. CHARTING » OCCLUSAL REALATIONSHIPS, TISSUE ABNORMALITIES » ORAL CANCER SCREENING
– Radiographic Exam
PROGRESS NOTES
FIRST ORAL DIAGNOSIS APPOINTMENT
• • • • •
MED/DENT HISTORY - 3A/3B RADIOGRAPHS FMX - qsi code 21 SOFT TISSUE EXAM / DENTAL CHARTING 4A/4B ALGINATE IMPRESSIONS DIAGNOSTIC TESTS
PROGRESS NOTES
SECOND ORAL DIAGNOSIS APPOINTMENT
• • • •
PERIODONTAL CHARTING (4B) PERIODONTAL WORKSHEET / DIAGNOSIS (4H) CONSULTS SELF ASSESSMENT ON TX. PLAN PRESENTATION
PROGRESS NOTES
THIRD APPOINTMENT
• ORAL DIAGNOSIS
– PRESENTATION OF TREATMENT PLAN – INFORMED CONSENT – PAYMENT ARRANGEMENT
• PERIODONTICS
– ADULT PROPHY / SCALING & ROOT PLANING – FL TREATMENT – ORAL HYGIENE INSTRUCTIONS
PROGRESS NOTES FIRST OD. APPOINTMENT
S-
OD H - SIGNIFICANT FINDINGS A - COMPREHENSIVE ORAL EXAM P - 3A, 3B, 4A, 4B-CHARTING, RADIOGRAPHS E - MED/DENT HISTORY, VITALS, HARD/SOFT TISSUE CHARTING, FMX., ALGINATE IMP. D - ORAL DIAGNOSIS - DATA 2
PROGRESS NOTE SECOND OD. APPOINTMENT
S-
ORAL DIAGNOSIS H - NO SIGNIFICANT CHANGES A - COMPREHENSIVE ORAL EXAM P - PERIO. CHARTING, 4H, RSD. CONSULT #3 E - PERIO. CHARTING & DIAGNOSIS. CONSULT #3, SEE 5A. D - PRESENTATION OF TX PLAN AND ADULT PROPHY.
PROGRESS NOTE - OD & PERIO TX PLAN & ADULT PRHPHY
S-
OD & PERIO H - NO SIGNIFICANT CHANGES A - DATA COMPLETED. PERIO DX: GINGIVITIS P - PRESENT TX PLAN AND ADULT PROPHY. E - TX. PLAN, INFORMED CONSENT, PAYMENT ARRANGEMENT, ADULT PROPHY, FL TX. OHI. D - RSD , #3 MOD AMAL..
PROGRESS NOTES
DENTAL
ANESTHETICS
• XYLOCAINE 2%
– 1:100,000 epinephrine – 1:50,000 epinephrine
• POLOCAINE 3% • CITANEST 4% plain • MARCAINE .5%
– 1:200,000 epinephrine
PROGRESS NOTES
SHAPED
FORMAT
• Mg. Dosage of Anesthetic administered • Mg. Dosage of Vasoconstrictor administered
– Calculation
– 1 carp. 1.8 ml – % of solution – % of epinephrine
PROGRESS NOTES
COMMONLY USED IN CLINIC
• XYLOCAINE 2% , 1:100,000 EPINEPHRINE
– 36 mg. xylocaine, .018 epinehprine
• POLOCAINE 3% , NO VASOCONSTRICTOR
– 54 mg. Polocaine.
PROGRESS NOTES
•
XYLOCAINE
# carps Mg Anes. Mg Epi.
2%
1 2 1 2
36 72 54 108
.018 .036
POLOCAINE
3%
PROGRESS NOTES - RSD.
S- RSD H- NO SIGNIFICANT CHANGES A- #3 SECONDARY DECAY AT MESIAL OCCLUSAL MARGINAL INTERFACE OF EXISTING DO AMAL P- #3 MOD E- MUCOSAL INFILTRATION, 36MG. LIDO., .018 MG. EPI., RUBBER DAM ISOLATION, REMOVED EXISTING DO AMAL. DECAY EXTENDED MESIALLY TO UNDERMINE MESIAL MARGINAL RIDGE. ACID ETCH, OPTIBOND PRIMER AND BOND. PLACED MOD AMAL, OCCLUSION CHECKED. D- RSD, MOD #5
PROGRESS NOTES
CLINIC
POLICY
• ADMINISTERED DENTAL ANESTHETICS RECORDED IN MILLIGRAM DOSAGES • POLICY EVALUATED THROUGH RANDOM • CHART AUDITS
PRESCRIPTIONS
PRESCRIPTION
WRITING
• Premedication • Pain Control • Dental Infection
PRESCRIPTIONS
PREMEDICATION
• Prevention of Endocarditis • AHA Guidelines, 1997 - Adult
– Standard Regimen
– 2 gms. Amoxicillin - one hour before dental procedure
– Patients allergic to amoxicillin
– 600 mg. Clindamycin One hour before dental procedure
PRESCRIPTIONS
DENTAL DENTAL
INFECTION PAIN
• PENICILLIN , 500 mg
• NARCOTICS
– LORTAB = Hydrocodone/aspirin – LORCET = Hydrocodone/acetaminophen – Percodan, Percocet = Oxycodone/acetamin./aspir.
PRESCRIPTIONS
PREMEDICATION
Rx:
Amoxicillin 500mg. Disp: 4 Sig: Take 4 tabs 1hr before dental appt.
PRESCRIPTIONS
Dental Infection
Rx:
Pen-Vee K 500mg. Disp: 28 Sig: take 1 tab q6h until gone
PRESCRIPTIONS
DENTAL
Rx:
PAIN
Lorcet 10/650 Disp: 20 Sig: Take 1 tab q4-6h PRN pain relief
PRESCRIPTIONS
STUDENT
RESPONSIBILITY
• MUST DEMONSTRATE THE ABILITY TO • WRITE PRESCRIPTIONS.
• DETERMINING THE DRUG AND DOSAGE IS ACCOMPLISHED THROUGH CONSULTATION WITH THE ATTENDING FACULTY. • PRESCRIPTION MUST BE SIGNED BY LICENSED DENTIST - REQUIRES DEA # AND LIC. #
PRESCRIPTIONS - ANTIBIOTICS
PRESCRIPTIONS - NARCOTICS