THE ODTP PROCESS

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THE ODTP PROCESS

• A Case-Based Overview
• Orientation to the Clinical Practice of General
  Dentistry, Fall Quarter
• Alan W. Budenz, MS, DDS, MBA

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Heather a new patient

• Screened by faculty September 26, 2005
• Designated as a 2nd Year teaching case

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Chief Concern (CC)

• I would like a bridge for my lower front teeth

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The ODTP Process Step 1Preparation

• Pre-appointment preparation
• Review chart
• Read screening and/or treatment notes
• Review health history
• Review radiographs
• Make notes
• Plan out the first appointment

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The Pacific Health History Questionnaire Form -
Comprehensive - Standardized - Translations
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The Pacific Health History Questionnaire Form

• Section 1 General Questions
• Designed to elicit general information about the
  patients health, and whether they have seen a
  physician recently, are currently in pain, or
  have had any problems with prior dental treatment.

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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.

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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.

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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.

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The Pacific Health History Questionnaire Form

• Section 3 Specific Diseases
• The patients 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.

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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 patients specific situation and the extent
  of the treatment and/or resultant outcome.

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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.

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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.

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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.

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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.

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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.

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The Pacific Health History Interview Sheet
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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
  patients Health Questionnaire form.
• The interview sheet is used to ensure that any
  positive questionnaire responses are followed up
  and appropriately documented.

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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?

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The Pacific Health History Interview Form

• 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.

• Cardiovascular problems?
• Infectious diseases?
• Allergies to medicines (or latex)?
• Bleeding problems?
• Take any medications?
• Other medical problems not asked about?

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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.

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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 dont need to take
  antibiotics before dental treatment?
• For heart murmurs specifically Was it termed
  functional or organic? Is there regurgitation?

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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...

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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.

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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

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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 patients
  physician may be indicated.

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The Pacific Health History Interview Form

• Take any medications?
• Indicates that the patients 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.

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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.

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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.

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The ODTP Process Step 1Medical History Review

• Yes answer to
• 3 Hospitalized or serious illness (3yrs)
• Listed Lung problem
• What questions do you want to ask?

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The ODTP Process Step 1Medical History Review

• Yes answers to
• 4 Being treated by physician
• Listed Anemia, GERD
• What questions do you want to ask?

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The ODTP Process Step 1Medical History Review

• Yes answers to
• 37 Stomach problems, ulcer
• What questions do you want to ask?

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The ODTP Process Step 1Medical History Review

• Yes answers to
• 62 Taking medications
• Listed Warfarin, Prevacid
• What questions do you want to ask?

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The ODTP Process Step 1Medical History Review

• Yes answers to
• 63 Tobacco
• What questions do you want to ask?

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Health History Review

• From your analysis of the medical history
• Is the patients medical condition controlled
  and stabilized under the supervision of a
  physician?
• Do you need to make any care delivery
  accommodations because of the patients health
  status?

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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)

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The ODTP Process Step 1Radiographic
Interpretation

• Patient has brought in an FMX dated 4/20/99. Do
  we need a new FMX?

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The ODTP Process Step 1Radiographic
Interpretation

• Complete a Radiographic Diagnosis Worksheet
  (available in Radiology)

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The ODTP Process Step 1Radiographic
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

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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.

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The First AppointmentD0150 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.

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The First AppointmentD0150 Initial Oral
Examination

• Give her a brief overview of what you are going
  to do this appointment
• Today Im going to do a very thorough
  examination of all of your teeth and gums, and
  then Ill 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.

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The ODTP Process Step 2Medical History
Interview/ Physical Exam/Vital Signs

1. Review the health history with the patient (MH)
2. Take vital signs (VS)
3. Perform intra- and extraoral exams (EOE IOE)
4. Take diagnostic casts if needed

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The ODTP Process Step 2Medical History
Interview/ Physical Exam/Vital Signs

• Health History Ask your questions from your Step
  1 review of the completed form and record
  Heathers responses to your questions on the
  Health History Interview Sheet.

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The ODTP Process Step 2Medical History
Interview/ Physical Exam/Vital Signs

• What is significant in Heathers health history
  for safe delivery of dental treatment?
• Where do you record this information?

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The ODTP Process Step 2Medical History
Interview/ Physical Exam/Vital Signs

• Do you still have questions about Heathers
  health?
• If so, how do you get them answered?

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The ODTP Process Step 2Medical History
Interview/ Physical Exam/Vital Signs

• Physical exam (PE) findings
• VS BP 105/70 R, pulse 77 reg.
• EOE IOE all WNL

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The ODTP Process Step 2Medical 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?

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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).

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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.

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The ODTP Process Step 2Medical 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.

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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

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The ODTP Process Step 3Periodontal Examination

1. Review x-rays, complete full mouth probing and
   comprehensive periodontal examination
2. Diagnose periodontal disease status
3. Plan periodontal treatment therapy
4. Plan follow-up/maintenance care

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The ODTP Process Step 3Periodontal Examination

• Chart all findings in the computer and on the
  buff-colored Baseline Clinical Examination form

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The ODTP Process Step 3Periodontal 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

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The ODTP Process Step 3Periodontal 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.

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The ODTP Process Step 3Periodontal 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.

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The ODTP Process Step 3Periodontal Examination

• What is Heathers 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.

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The ODTP Process Step 4Oral Hygiene Instruction

• Full instruction customized to your patients
  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.

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The ODTP Process Step 5Dental Occlusal
Exam/Problem Listing

1. Charting of restorations, caries, pathology
2. Ortho/occlusion screening
3. Caries risk assessment
4. List all findings and tentative solutions

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The ODTP Process Step 5Dental Occlusal
Exam/Problem Listing

1. Charting of restorations, caries, pathology in
   the computer
2. Ortho/occlusion screening in the computer and on
   Orthodontic Screening form

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The ODTP Process Step 5Dental Occlusal
Exam/Problem Listing

• Caries risk assessment on Caries Risk Assessment
  form.
• What is the patients risk level and how will
  we, the patient and you together, manage their
  caries risk level?

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The ODTP Process Step 5Dental Occlusal
Exam/Problem Listing

• 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.

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The ODTP Process Step 5Dental Occlusal Exam

• View of Heathers maxillary arch

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The ODTP Process Step 5Dental Occlusal Exam

• View of Heathers mandibular arch

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The ODTP Process Step 5Dental Occlusal Exam

• Anterior view of Heathers dentition

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The ODTP Process Step 5Dental Occlusal Exam

• View of Heathers right lateral side

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The ODTP Process Step 5Dental Occlusal Exam

• View of Heathers left lateral side

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The ODTP Process Step 5Dental 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

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The ODTP Process Step 6Tentative Treatment Plan

1. Determine the ideal treatment options for the
   various dental problems found.
2. Determine appropriate alternative treatment
   choices for the dental problems found.
3. Discuss treatment goals with the patient.

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The ODTP Process Step 6Tentative Treatment Plan

• In Heathers case, her dental problems are
• Moderate generalized periodontitis disease with
  localized severe disease
• Caries on the Mesial of 2
• Severe bone loss mobility 23, 24, 25
• What treatment options does she have?

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The ODTP Process Step 6Tentative Treatment Plan

• Moderate to severe periodontitis
• What treatment options does she have?
• 4 quadrants of root planing
• No treatment
• What are the risks, benefits, and alternatives
  (RBAs) of each option?

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The ODTP Process Step 6Tentative Treatment Plan

• Caries on the Mesial of 2
• What treatment options does she have?
• M or MOL amalgam
• Full veneer crown (FVC)
• No treatment
• What are the risks, benefits, and alternatives
  (RBAs) of each option?

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The ODTP Process Step 6Tentative Treatment Plan

• Severe bone loss mobility 23 25
• What treatment options does she have?
• Re-evaluate following perio therapy
• Extract and replace teeth with?
• No treatment
• What are the risks, benefits, and alternatives
  (RBAs) of each option?

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The ODTP Process Step 6Tentative 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.

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The ODTP Process Step 6Tentative 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.

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The ODTP Process Step 6Tentative 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.

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The ODTP Process Step 7Treatment
Prioritizing/Contract

1. Prioritize and finalize the treatment plan with
   the patient and review it with the ODTP
   instructor.
2. Enter the treatment into the computer in
   prioritized sequence, print it out and have the
   patient sign the printout.
3. Have the ODTP instructor clinically approve your
   treatment plan in the computer.

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The ODTP Process Step 7Treatment
Prioritizing/Contract

• For Heathers case, the priorities are
• 4 quadrants of root planing
• M amalgam on 2
• Re-evaluate perio health for status of 24 25.
  Are these teeth salvageable? If not, what
  replacement options does she have?

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The ODTP Process The Final Step

• At the completion of your appointment, or during
  down times during the appointment,
• Write up your treatment record.

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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.

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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! (Its only
  going to get worse!)
• Learn how to make the paperwork serve your needs.
• The palest ink is stronger than the best
  memory.

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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 isnt written down, it didnt happen.

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Treatment Records

• The complete record contains a description of
  the patients original condition, your diagnosis
  and treatment plan, progress notes on the
  treatment performed and the results of that
  treatment. It should also contain the patients
  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.
• (Dentists Guide to Keeping Patient Records
  Strategies Solutions, California Dental
  Association, 1996)

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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 patients involvement in care.
• This ongoing record is the practicing dentists
  first reference at every subsequent patient visit.

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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)

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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 patients 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.

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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.

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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.

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Treatment Records

• 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.

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Treatment Records

• Ten rules for complete patient records
• Use a single line to cross out errors.
• 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.

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Treatment Records

• 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

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Treatment Records

• Ten rules for complete patient records
• Express your honest concerns about patient needs
  this reflects an understanding of the patients
  needs and documents that the dentist listened to,
  noted, and possibly addressed the patients
  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.

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Treatment Records

• 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 patients 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

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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

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Treatment Records

• The SOAP note entry format
• S Subjective
• O Objective
• A Assessment
• P Plan/Procedure

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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

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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

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Treatment Records

• The SOAP note entry format
• A Assessment
• What is your diagnosis?
• Includes
• Periodontal diagnosis
• Caries risk assessment
• Restorative diagnosis
• Addresses patients chief concern

100
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

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The Treatment Record S.O.A.P. Notes

• For ALL procedures
• First line the date and procedure code and
  description

102
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)
• ID Patient age, sex, etc.
• CC Chief Concern
• HCC History of Chief Concern
• MH Medical History
• DH Dental History
• SH Social History

103
The Treatment Record S.O.A.P. Notes

• For ODTP we use an extended SOAP note
• (O Objective)
• PE Physical Exam (VS, EOE, IOE, TMJ)
• Perio Dx Periodontal Exam findings
• RE Radiographic Exam findings
• Hard Tissue Exam findings

104
The Treatment Record S.O.A.P. Notes

• For ODTP we use an extended SOAP note
• (A Assessment)
• Periodontal Diagnosis
• Hard Tissue Diagnosis
• Caries Risk Assessment
• Make sure the patients CC is addressed!

105
The Treatment Record S.O.A.P. Notes

• For ODTP we use an extended SOAP note
• (P Plan/Procedure)
• Includes complete notes on
• DWP Treatment plan discussion RBAs options
  and decisions
• Treatment plan or procedures done
• Instructions, recommendations, referrals,
  prescriptions
• NA or NV Next Appointment or Visit

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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

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Treatment Records

• Patient privacy (HIPPA)
• Patient privacy must be respected at all times
• Charts must be regarded as confidential,
  privileged information
• Patients 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

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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

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Patient Presentation

• 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 Im 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.

S
O
A
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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.

111
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.

112
That's All, Folks!
Unless
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