Standardized Format for Progress Notes
A standardized format for Progress Notes will be used for all patient record entries, except for Oral Surgery that already uses a standardized SOAP note. The “data elements” and “examples” of the Progress Note format are shown below.
Data Elements of Progress Note
| A: |
Assessment – reason for visit; pt. health/medical management considerations; consent |
| T: |
Treatment – concise and detailed description of procedures performed and medications |
| E: |
Evaluation – appraisal of treatment; patient’s reaction to treatment; extenuating circumstances |
| N: |
Next Visit – specific plans for next visit |
Examples of Progress Note
Date
| A: |
Patient presents for tx of occlusal caries on #19; no Changes in med. hx. since 1/15/99; pt. understands risks of today’s tx and reaffirms consent. |
| T: |
Mandibular block with 1.8 cc 2% Xylocaine; 1:100,000 epi.; rubber dam; #19 occlusal caries removal, CaOH2 (Dycal), Vitrebond, amalgam (Contour) restoration. |
| E: |
Patient apprehensive as usual regarding local anesthesia; deep caries approaching pulp, but no exposure; patient advised that tooth could need endodontic therapy; treatment completed. |
| N: |
6 month recall, check for caries progression on mesial of #3 by radiograph. |
Student Signature & #
Faculty Signature & #
Date
| A: |
Patient presents for SC/RP of ULQ; reports new RX, nifedepine for hypertension; BP right arm sitting: 145/80; pt. understands risks of today’s tx and reaffirms consent; plaque score: 65%. |
| T: |
Reinforced home care instructions, showed patient literature on gingival hyperplasia associated with nifedepine; local infiltration in area of #14 with 0.5ml of 2% Xylocaine with 1:100,000 epi.; ultrasonic removal of gross calculus followed by hand curette scaling and root planing; irrigated DL pocket of #14 with sterile saline. |
| E: |
Patient understands risk for hyperplasia, showed extra motivation to follow home care; 7mm pocket DL #14 difficult to complete instrumentation due to furcation; revaluation required. |
| N: |
Next visit 10/27/99: URQ SC/RP, whole mouth polish and fluoride; check tissue response and finish RP of distal furcation #14 before starting URQ. |
Student Signature & #
Faculty Signature & #
- At the end of each appointment period, all clinical services rendered during the appointment must be recorded on the "Continuation Sheet" of the patient's chart. This form must have a signature (no initials) and Provider Number recorded by the instructor supervising the student during the appointment period. An entry in Axium must be made for each appointment.
- Using the ATEN system of chart entries, the following information should be listed in the continuation notes: 1) date, 2) department, 3) tooth number, 4) diagnosis, 5) treatment listing all restorative materials (with brand names following each in parenthesis), 6) use of rubber dam, 7) appropriate remarks and/or post-operative instructions listed under E (Evaluation). Standard accepted abbreviations maybe used. Students and faculty must sign every entry and included their provider number.