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INITIAL ASSESSMENT APPOINTMENT

I. PATIENT CHECKS IN AT THE FRONT DESK. A. Administrative Data Entry, Initial Consent for Treatment and Payment for the Screening Exam/Radiographs will occur at the Front Desk prior to you seating patient. II. SEAT YOUR PATIENT. A. Check to see the Pt is checked in in Axium. They should be red in Scheduler window. B. Do not forget to inform your supervising faculty when you are starting. C. Discuss the WVU School of Dentistry Student Dental Practice Information handout, previously mailed to the patient. 1. Emphasize time commitment needed of patients treated in the student dental clinic. 2. Remind the patient that payment is expected at the time of service. 3. Remind pt that if cost is prblm, they may finance dental care thru Wells Fargo. D. Open the patients EHR. III. SUBJECTIVE A. Medical History EHR Form is completed. B. Dental History EHR Form is completed. C. Medical and Dental History is approved by Faculty. D. Note: You can start your Treatment Plan/Initial Assessment Problem List at this time and enter the Chief Complaint/Concern on both the Dental History and the Treatment Plan/Initial Assessment Problem List with copy/paste. IV. OBJECTIVE A. OroFacial Exam EHR Form is completed. B. PSR is completed. C. Orofacial Exam and PSR approved by Faculty. D. Radiograph Request Notes are entered and approved by Faculty. Usually 4 bite wing (vertical [4 or more] or horizontal) and panoramic radiographs are ordered. Another combination of radiographs may be customized to suit the patients clinical needs. 1. From the EHR, select the Tx History tab. Click on the Add a new Note icon.

2. Gen Note window opens. Click on ellipses to open pre-written clinical notes window.

3. From the categories in the Select Clinical Note Codes window, select INTRAORAL RADIOGRPAHS by double clicking RAD-A.

4.

The Select Clinical Note Codes window expands to show procedures. a) Double click the appropriate procedure. b) Procedure copied to Selected Comments section. c) Click OK to add procedure to Gen Note window.

4. The General Note window is populated with the procedure.

5. Similarly add a note for a panogram by: clicking on the ellipses, selecting EXTRAORAL RADIOGRAPHS, and the note for the panoramic radiograph. Click on Add New to add the note to the EHR as shown below.

6. Have Faculty approve by clicking on the light blue chart number rectangle at the bottom of the screen and highlighting the procedure and approving. E. Note: Radiographs are reviewed but the Radiographic Interpretation Form is not utilized at this time. The radiographs are utilized to develop the patients Problem List.

V. ASSESSMENT - TENTATIVE TX PLAN CALLED INITIAL ASSESSMENT PRBLM LIST A. Go to patients EHR B. Click: Tx Plan tab

C. Click on the Create a New Record Icon

D. Click: Problems Tab

E. Enter in Plan Description box: Initial Assess Problem List F. Enter Chief Concern in quotes

G. Complete Problem List from prepared items by 1. clicking on Update

2.

The Update Problems window opens.

3. Select a category by clicking on a a) Type in the Site for the procedure.

to open the list of problems.

4. Select a Problem from the menu with a single click. b) You can type in a note but this information does not appear on the Problem List. c) Do not use the Area Found, Problem Type or Status options 5. Finish by a) double clicking the Problem or b) clicking on the Add a New Record icon

6. You can Modify or Delete a problem using the icons 7. Close the completed problem list by clicking on the X in the upper right.

8. Enter any Other Problems not covered by prepared items in the Chief Concern box. Be brief as the space allotted for this is very limited.

H. Problems List is approved by Faculty. Once approved, items cannot be added or deleted from the Problem List. A problem can be edited, i.e. a site added.

VI. PLAN - DISCUSS THE PROBLEM LIST WITH THE PATIENT AND HOW CARE AT THE SOD USUALLY PROCEEDS. THE PATIENT WILL RETURN TO CLINIC FOR: A. Simple Treatment Planning Appointment, B. Complex Treatment Planning Appointment, C. Acute Care 1. Acute Care Treatment Planning Appointment or 2. Acute Care in Endo/Oral Surg Clinic to be followed by comprehensive tx planning apt. VI. PROCEDURES & TREATMENT NOTE ARE ENTERED INTO AXIUM AND APPROVED. A. Completed Procedures are entered; Initial Assessment Exam Code (D0191) is entered. Check to see that Radiology Codes have been entered. B. Treatment Note entered in SOAP note format includes: 1. Examinations and EHR Forms completed 2. Consultation List. 3. Plan for the next visit as described above. C. Treatment Note & Procedures are approved by Faculty. D. Dismiss patient. 1. If 4 BWs & pan were only images captured, pt should have a $0 balance & do not need to stop at front desk. Check Out pt in Axium Scheduler, they will turn grey. 2. If additional RGs, only 2 BWs or other combo of images were captured, the pts will usually have a balance or possibly credit & need to stop at Front Desk to Check Out. VII. EXAMPLE OF A TREATMENT NOTE FOR A INITIAL ASSESSMENT APPOINTMENT 4 BWs to assess caries & crestal bone level. Intra-oral Findings EHR form to be completed. Panoramic RG to assess dentition, crestal bone level & bones of mandible & maxilla, areas adjacent to maxilla & mandible, soft tissue & air spaces. Panoramic fndings to be completed. Initial Assessment Evaluation: Pt evaluated by clinical & RG examination. All appropriate forms completed & data collected. S: "I want a second opinion on my recent root canal. I haven't been happy with my previous dentist, and WVU SOD is more affordable." MH DH O: OFE PSR. Exposed 4 BW and Pano A: Problem List completed. Pt has operative needs that need to be addressed. Full perio mouth charting and FMX. BW and Pano have no significant findings other than recurrent decay and generalized HBL. #26 has open margin and sensitivity. Restorability questionable. Advised pt to replace filling if possible or extract if not. P: Return for Treatment Plan Consultations Indicated: Endodontic Oral Surgery Medical Consultation Letter Periodontal Operative Prosthodontics Oral Pathology Patient accepted for treatment in SOD student clinic and referred to the Coordinator, Predoctoral Clinical Education for assignment.

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