Notation in OMS Flashcards
1
Q
INTRODUCTORY STATEMENT
(4)
A
- 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.
2
Q
CONSENT DISCUSSION
(2)
A
- “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
3
Q
VITALS
A
- Blood pressure and Heart Rate BOTH are recorded
- “BP: 120/80, P: 64”
4
Q
LOCAL ADMINISTRATION
A
- “Topical local placed in anticipated injection sites (L PSA, L MSA)
2 cartridges 2% lido w/ 1:100k epi given as L PSA, L MSA, L GP blocks. Aspirations all
negative. *Total 72 mg lidocaine, 0.036 mg epi delivered”
*additional if desired but not required
5
Q
PROCEDURAL NOTE
(3)
A
- 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
6
Q
PROCEDURAL NOTE – MAXILLARY TOOTH
A
- “After profound anesthesia achieved, throat pack and bite block placed. #9 molt
periosteal elevator used to reflect suclular mucosa around tooth #14. Straight elevators
used in success to luxate #14, making sure to avoid excess force on adjacent dentition.
Forceps used to deliver tooth #14 in total. No visualization of sinus membrane. No
purulence, no granulation tissue. Socket irrigated with sterile normal saline. Throat pack
and bite block removed. Compression gauze placed. Hemostasis achieved.”
7
Q
PROCEDURAL NOTE – MANDIBULAR TOOTH
A
- “After profound anesthesia achieved, throat pack and bite block placed. #9 molt
periosteal elevator used to reflect sulcular mucosa around tooth #19. Straight elevators
used in success to luxate #19, making sure to avoid excess force on adjacent dentition.
Forceps used to deliver tooth #19 in total. No visualization of IAN. Lingual cortex
intact. No purulence, no granulation tissue. Socket irrigated with sterile normal saline.
Throat pack and bite block removed. Compression gauze placed. Hemostasis achieved.”
8
Q
POST-OP INSTRUCTIONS
* Main goals here are:
(4)
A
- To provide wound care, and hygiene instructions during the healing period
- To provide diet recommendations during the healing period
- Discuss post-operative pain expectations and medication instructions
- Provide emergency contact information
9
Q
POST-OP INSTRUCTIONS
A
- Post-op instructions given to patient verbally as well as in paper form
- Regarding pain expectation, they can vary wildly from patient to patient so always prepare the patient for the worst
- If the worst occurs, they will remember that it was expected and not call you at midnight on Saturday
- If the worst does not occur, then you are “the best surgeon I have even had!!!”
10
Q
D/C RX
(2)
A
- If no narcotics needed, i.e. for single tooth simple extractions, document no discharge (D/C)
prescription (Rx) given, but document over-the-counter pain medication recommendations - If narcotics given, i.e. multiple extraction or a single surgical extraction or prosthetic surgery,
document everything that would be found on the prescription form, including refills
11
Q
RETURN TO CLINIC INFORMATION
(3)
A
- RTC prn
- RTC in 2 weeks for post-op treatment evaluation of surgical TE #31
- RTC in 4 weeks for continuation of treatment, TE lower right quadrant #24-31 with
associated alveoloplasty under LA w/ N2O adjunct
12
Q
WHY DO DENTISTS WRITE PRESCRIPTIONS
(8)
A
- Infection
- Pain management
- Pre-medication
- Anxiety
- Saliva control
- Saliva replacement
- Caries control
- Periodontal disease control
13
Q
FORMAT
* THIS IS A LEGAL DOCUMENT!!!
* Should include:
A
- Patient’s full name and address
- Prescriber’s full name, address, telephone number,
DEA number (for controlled substances) - Date of issuance
- Signature of prescriber
- Drug name, dose, dose form, amount
- Directions for use
- Refills instruction
14
Q
- Q =
A
“quaque” or “every”
15
Q
- Qday =
A
“quaque die” or “every
day”
16
Q
- h =
A
“hora” or “hour”
17
Q
- BID =
A
“bis in die” or “twice a day”
18
Q
- TID =
A
“ter in die” or “three times
a day”
19
Q
- QID →
A
no longer used due to confusion
with QD when hand written, AMA recommends Q6H
20
Q
- hs =
A
“hora somni” or “at bedtime”
21
Q
- PO =
A
“per os” or “by mouth”
22
Q
- PRN =
A
“pro re nata” or “as needed”
23
Q
- Sig =
A
“signetur” or “let it be labeled”
24
Q
- AC =
A
“ante cibum” or before meals”
25
Q
BODY OF THE PRESCRIPTION
* Superscription:
* Inscription
(2)
* Subscription and refill information
(2)
* Transcription = (3)
A
Rx = “take thou”
- Name of the medication (generic and brand)
- Strength and dosage to be dispensed
- Instruction to pharmacist for quantity of medication
- Refill or not
Sig. = “singetur” or “let it be labeled”
* Directions for use: route, interval, duration, purpose
* Other instructions
26
Q
CONTROLLED SUBSTANCE PRESCRIPTION
* Schedule I:
(3)
A
- 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
27
Q
CONTROLLED SUBSTANCE PRESCRIPTION
* Schedule II:
(4)
A
- 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
28
Q
CONTROLLED SUBSTANCE PRESCRIPTION
* Schedule III:
(3)
A
- Potential for abuse, but less than schedule I and II
- Has currently accepted medical use in treatment in US
- Abuse may lead to moderate or low physical dependence or high psychological dependence
- Examples: codeine compounds, anabolic steroids, ketamine
29
Q
CONTROLLED SUBSTANCE PRESCRIPTION
* Schedule IV:
(3)
A
- 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
30
Q
CONTROLLED SUBSTANCE PRESCRIPTION
* Schedule V:
(3)
A
- 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
31
Q
SOME THINGS TO KEEP IN MIND
* Keep prescription pads and paper in a safe place!?!
* Rarely do practitioners use —
* Most print prescriptions from computer
* Never sign in —
* Report stolen blanks to — immediately
* Write number of pills in — to prevent addition of “0”
* 10 tabs converted to 100 tabs
* Avoid writing for large number of —
A
actual paper pads
advance
DEA
words
pills
32
Q
- Vicodin, Lortab, Norco
(2)
A
- Hydrocodone/Tylenol
- 5/300, 5/325, 7.5/300, 10/300
33
Q
- Percocet 5/325, 10/325
(1)
A
- Oxycodone/Tylenol
34
Q
- Ibuprofen
(3)
A
- NSAID
- 600 mg (Rx), 200 mg OTC
- Caution in preggers (!! After 32 weeks!!)
35
Q
- Tylenol #2, #3, #4
(2)
A
- 15/300, 30/300, 60/300
- NO LONGER GIVEN TO PEDS PTSDisp: #10 (ten)
36
Q
- Pen VK 500 mg
A
- 4 tabs per day x 5-7 days
37
Q
- Amoxicillin 500 mg
A
- 3 tabs per day x 5-7 days
38
Q
- Augmentin 875/125 mg
(2)
A
- “Augmented” Amoxicillin 875 mg
- Clavulanic Acid (125 mg) added
39
Q
- Cephalexin 500 mg
(2)
A
- 4 tabs x 5-7 days
- 0.2% to 8% cross reactivity to PCN
40
Q
- Clindamycin 150 mg, 300 mg
(3)
A
- At least 900 mg per day x 5-7 days
- Good activity against Gram +, anaerobes
- 50S subunit of ribosome attacked
41
Q
- Metronidazole 500 mg
(3)
A
- 3 tabs per day x 5-7 days
- Great activity against anaerobes
- Disulfram rxn, potentiates Warfarin
