PROGRESS NOTES

1
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

2
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

3
PROGRESS NOTES

• SECOND ORAL DIAGNOSIS APPOINTMENT
• PERIODONTAL CHARTING (4B)
• PERIODONTAL WORKSHEET / DIAGNOSIS (4H)
• CONSULTS
• SELF ASSESSMENT ON TX. PLAN PRESENTATION

4
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

5
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

6
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.

7
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..

8
PROGRESS NOTES

• DENTAL ANESTHETICS
• XYLOCAINE 2
• 1100,000 epinephrine
• 150,000 epinephrine
• POLOCAINE 3
• CITANEST 4 plain
• MARCAINE .5
• 1200,000 epinephrine

9
PROGRESS NOTES

• SHAPED FORMAT
• Mg. Dosage of Anesthetic administered
• Mg. Dosage of Vasoconstrictor administered
• Calculation
• 1 carp. 1.8 ml
• of solution
• of epinephrine

10
PROGRESS NOTES

• COMMONLY USED IN CLINIC
• XYLOCAINE 2 , 1100,000 EPINEPHRINE
• 36 mg. xylocaine, .018 epinehprine
• POLOCAINE 3 , NO VASOCONSTRICTOR
• 54 mg. Polocaine.

11
PROGRESS NOTES

• carps Mg Anes.
  Mg Epi.
• XYLOCAINE 1 36
  .018
• 2 2
  72 .036
• POLOCAINE 1 54
• 3 2 108

12
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

13
PROGRESS NOTES

• CLINIC POLICY
• ADMINISTERED DENTAL ANESTHETICS RECORDED IN
  MILLIGRAM DOSAGES
• POLICY EVALUATED THROUGH RANDOM
• CHART AUDITS

14
PRESCRIPTIONS

• PRESCRIPTION WRITING
• Premedication
• Pain Control
• Dental Infection

15
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

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PRESCRIPTIONS

• DENTAL INFECTION
• PENICILLIN , 500 mg
• DENTAL PAIN
• NARCOTICS
• LORTAB Hydrocodone/aspirin
• LORCET Hydrocodone/acetaminophen
• Percodan, Percocet Oxycodone/acetamin./aspir.

17
PRESCRIPTIONS

• PREMEDICATION
• Rx Amoxicillin 500mg.
• Disp 4
• Sig Take 4 tabs 1hr before dental appt.

18
PRESCRIPTIONS

• Dental Infection
• Rx Pen-Vee K 500mg.
• Disp 28
• Sig take 1 tab q6h until gone

19
PRESCRIPTIONS

• DENTAL PAIN
• Rx Lorcet 10/650
• Disp 20
• Sig Take 1 tab q4-6h PRN pain relief

20
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.

21
PRESCRIPTIONS - ANTIBIOTICS
22
PRESCRIPTIONS - NARCOTICS