Examination and Treatment Planning Flashcards
Examination and diagnostic techniques used for assessment
The dental assistant’s responsibilities begin as the patient walks through the front door.
The patient record
The patient record is all information recorded on a patient including clinical history, examination, treatments.\
-Purpose of the record:
* risk management
* documentation of the patient’s conditions
*A source of data for research purposes.
-patient record stooge: must stored in a located room. should always facedown.
-patient records and HIPAAA: keeping patient records private is law.
Gathering patient information
- by interviewing them
- address the patient using usermae
- explain why you need to obtain information
- answer any questions the patients may have.
- Smile
Before any dental treatment is provided
- patient-registration
- medical-dental health history
- medial alert infromation
patient-information form
Registration forms provide demographic and financial information about the patient and dental fee
- Patients information: including name, date of birth, residence, phone #, emergency contacts, place of employment and spouse’s information.
-Insurance information: employee’s information, and data of birth. employer’s information name, address, and phone #. make a copy of the card with name of the insurance carrier and patient’s policy number.
-Responsible financial party: It is to note the name of the person responsible for payment of the account. This may be different from the patients.
-Patients signature and data: documents must have a signature with data to confirm that all of the information is correct.
Medical and dental history
Dental history: it is important because it lets the entire dental staff know what procedures or treatment the patient has or has not had in the past. history about their feeling or past issue.
Medial history: important because it highlights the patient’s current physical conditions. what allergies might this person have? medications are they taking?
Updata medical and dental history form
health changes occur to people over time. all patients should be required to update their medical-dental history every time they come in.
- Have you been diagnosed with any are medical conditions?
- Are you taking any new or different medications or has your dosage changed.
medical Alert information
After a patients has filld out the form, it is your job to review them and lokk for anything that warrants special attention. medical alerts may be anything for an allergic condition to medication that could potentially interfere with dental treatment or care.
If you spot such a condition, immediately place an alert sticker inside the patient’s record in a locations that seen and put the notes in the electronic patient record.
This stickers should be placed inside the chart not not the outside of the folder where it would be visible to other.
The clinical examination form
Forms is filled out for every new patient and provides a rich amount of details for the dental team.
- about the past, present, future examinations
- notes of exist restorations and present conditions
- charting of periodontal conditions
- patient’s chief complaint
During the clinical examination the dentist
- assesses the patient oral condition
- make diagnosis
-determines the type of treament that best
-schedules appointments to provide treatment in timely manner
- follow through with maintenance stage of the patient care process.
Treatment plant form
The registration form is filled out and the clinical examination has been done. the next step is to complete the treatment plant form. the purpose od this form is to record any dental problem that were discovered during examination process and provide diagnosis.
The treatment plant’s provide a diagnosis implementation may need to change if a patients condition or finances warrant it.
treatment plant form: document that outline how patent treatment should progress.
The progress notes form
Progress notes: part of the official record in which the dental professionals keeps notes in the continuing care and any change in patients health status.
Notes also include phone conversations with patient, any missed appointments, and communications to and from the insurance carries.
progress notes section of the patient record is where any treatment is recorded. include data, number of tooth was treated. the treatment that was completed and the signature of the dentist who performed the care.
the informed consent form
Patients need to be educated about educated results of any recommended treatment or procedure. Once this has been done the patient, dentist and witness all sign an informed consent form.
Informed consent form: used by dental office to detail the possible risks of procedures or risks that are of importance to the patients the acknowledge the risks of the procedures.
When are informed consent forms used? commonly used when patients required invasive or extensive?
invasive: root anals and dental surgery
extensive: orthodontics, endnotes, periodontics and implants.
Recording the dental examination
Dental assistant’s responsibilities is to record the finding from the dental examination . This information will be used by the dentist to make a diagnosis and design a treatment plan.
Before you can record information in the patient’s chart, you need t be familiar with several basic criteria.
- Black’s classifications of cavities
- the standard dental charting used for diagramming teeth
- the three most frequently used system for numbering teeth
-the symbols used in color coding
-common abbreviations - The standard symbols used in patient charting
Color coding
Color coding: system used on patient dental charts to convey important information about teeth. the Color coding helps to indicate which procedure have been completed and which have yet to be completed.
Color coding used to clarify which treatments have already been done
Black or blue symbols indicate completed dental work
Red symbols treatment the needs o be completed.
After work is completed the assistant will erase or mark over the red with blue or back to indicate that the treatment has been finished.
Examination and diagnostic technique used for assessment
visual evaluation is first step involved diagnosing any dental examination.
using a variety of tools to explorer, mouth mirror, dental light
dentist looks at four distinct area inside mouth for any sign of trouble: soft tissue, tooth structure, restorations and missing teeth.
- is the soft tissue a light pink color with no swelling?
- is tooth structure intact with enamel that is not discolored or chipped?
- Are there any restoration still completely covered and sound?
- are there any missing teeth that should be noted on the patient record?
The Dental Examination
After examination is complete. the dentist uses his or her fingers and hands to examine the patient ‘s hard and soft tissue. This method is called
palpation.
palpation: examination method in which feels the size, shape, firmness and location and structures.
Type of examination is done to check tissue for firmness, size, consistency.
After the dentist has used his or her eyes, fingers and hands, dental instrumentation like tools is brought into the exam process. instrumentation used to examine teeth and tissues around them. sharp pointed tools are commonly used to look for problem in surface of the tooth’s enamel that might indicate decay.
