Notation in OMS Flashcards
- Age and gender of patient first (identifiers)
- If speak any other langue document this next
- Then document where they are currently at (OMS clinic)
- Then document for what reason.
INTRODUCTORY STATEMENT
• “Risks, Benefits, and Alternatives discussed with the patient regarding current treatment
(TE #14). Complications also discussed with the patient including but not limited to pain,
swelling, bleeding, infection, need for further surgery, sinus exposure, permanent or
temporary nerve damage, damage to adjacent structures, dry socket (as pt is a smoker
and diabetic). All questions answered to pattient’s satisfaction. Consent signed.”
• If extracting mandibular molar, remove sinus exposure (no sinus on mandible) but add
risk for jaw fracture
CONSENT DISCUSSION
What vitals are recorded?
HR and BP
- Goal is to write the exact steps performed during any procedure
- Write the note like you are addressing someone who works in the front office
- They may not know all the specific wording, but could be able to understand what occurred
PROCEDURAL NOTE
• If no narcotics needed, i.e. for single tooth simple extractions, document no discharge (D/C)
prescription (Rx) given, but document ______ pain medication recommendations
over-the-counter
- High potential for abuse
- No currently accepted medical use in treatment in US
- Lack of accepted safety for use of drug under medical supervision
- Examples: heroin, LSD, MDMA, mescaline, methaqualone
•Schedule I:
• High potential for abuse
• Currently accepted medical use in treatment in US
• Or currently accepted medical use with severe restrictions
• Abuse may lead to psychological or physical dependence
• Examples: Methamphetamine, cocaine, fentanyl, hydro/oxycodone, and hydro/oxycodone
combinations, methadone, hydromorphone, Adderall
•Schedule II:
- Low potential for abuse
- Has currently accepted medical use in treatment in US
- Abuse may lead to moderate or limited physical dependence or psychological dependence
- Examples: Benzodiazepines, muscle relaxers, tramadol, ambien
•Schedule IV:
- Low potential for abuse
- Has currently accepted medical use in treatment in US
- Abuse may lead to moderate or limited physical dependence or psychological dependence
- Examples: Cough suppressants with codeine, pregabalin, lomotil
•Schedule V:
What is max dose of tylenol that can be taken?
4 g
What is max dose of ibuprofen that can be taken?
3.2 g