Hard Tissue Charting Codes
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Chart note entries in the EPR
While there are templates for chart notes in the EPR, chart notes should be written in the standard dental school form including all areas of the S.O.A.P. format as follows:
S=Subjective
What the patient tells you
Patient’s chief complaint, history of present illness (this complaint) Past medical history, past dental history
Example: Patient presents complaining of missing tooth #7. States that the tooth was extracted after an unsuccessful attempt at restoration (use quotations when appropriate). Past medical history is non-contributory, however patient admits to smoking 1/2 pack per day of cigarettes. Past dental history: Patient receives dental cleanings irregularly, does not use floss.
O=Objective
- what you see in your examination, including radiographic
- information obtained in your EIOE, gingival/perio assessment, HTC, etc.
- radiographic findings bone levels, caries, pathology
Example: Intra-oral exam reveals tongue, palate, FOM WNL. Gingiva is pink and stippled with localized swelling and redness in lower anterior and maxilla posterior regions. Pocketing and dentition as charted (see charting). Missing tooth #7. Adjacent teeth #6, 8 show slight drifting into space of #7. Slight plaque, moderate stain.
Slight stick to explorer in occlusal pits maxillary premolars, however bite-wing radiographs reveal no sign of decay. #31 with large IRM. Radiographic exam reveals IRM #31 is close to pulp. Bone loss seen in area of #23- 26.e
A=Assessment
- problem list, or diagnoses. It works well to number these and make corresponding remarks in the '"'Plan'"' section.
Example:
- Missing #7
- Localized periodontal disease #23-26
- #31 restoration close to pulp, poss. pulpal pathology
- Max. premolars non-carious
P=Plan
- what you plan to do, and what you did today. Try to address each problem.
- Patient disposition pleasant, agitated, friendly, etc.
- Interval of recall 3 mo recall
- Planned treatment for next visits Ex, perio main, 4BW
- Referrals to other departments OS for evaluation of lesion R lateral border of the tongue
- Areas that require re-evaluation check 2 M incipiency on next BW
- All services rendered
Include instrumentation, methods and materials used. Such as 4 vertical BW exposed, scaled/Root planned maxillary molars with Gr11/12, 13/14, scaled all other teeth with Un 13/14,204S, rubber cup polish with extra fine paste, dried all teeth and placed 5% Fluoride Varnish. Gave post treatment instructions.
- Local and/or topical anesthesia used
Type, method of delivery, amount and with or without epinephrine (amount of epi). Obtain signature of student (if other than yourself) or faculty who administered the anesthetic.
- Any recommendations made by student or faculty
Homecare, dietary counseling, habit modifications, referrals, etc.
Include anticipated outcome of your recommendations and the mechanism of measurement.
- Note that radiographs were evaluated by dental faculty when applicable
Example:
Today: Examination, full mouth series radiographs taken and read. Alg. imps for study
- Explained to patient that there are several different ways to restore missing #7. Will review study casts and discuss options and fees at next appointment.
- Expl'd to patient need for more frequent prophy, and the use of floss.
- Will eval pulpal status of #31 with endodontic consult
- Recommend no treatment for occlusal fissures of premolars RTC (Return to clinic) Discuss treatment plan options. Chart entries for initial visits, periodic evaluations, and emergency visits are well understood and legally complete if written in the form of a SOAP note. Subsequent treatment visits do not need such detail.
ALWAYS HAVE ALL FACULTY AND STUDENTS THAT WORKED WITH THE PATIENT SWIPE IN AXIUM.
ALWAYS DOCUMENT IF PATIENT ARRIVED LATE, CANCELLED OR DID NOT SHOW FOR AN APPOINTMENT AND ANY PHONE CALLS YOU MADE TO THEM REGARDING THE APPOINTMENT.