Tutorial: Every encounter with a patient at our dental office receives some kind of an exam. That’s just what we do. Usually accompanied with the exam is either a single x-ray, panograph, 7 vertical bitewings, or as many as a full series. While most dentist around the world only note that the exam was done and x-rays were taken, I feel it is best to write up a complete S.O.A.P. note for each encounter.
This is the template for writing our office’s “X-ray/Exam note” and I will show you just how to code it in PracticeWorks.
<radioType> taken today <taken> with a lead apron and were reviewed by <doctor>. SUBJECTIVE:<HlthHx> Chief complaints include <CC> <CC> <CC> <CC> <CC> <CC> <onlyExt>OBJECTIVE:Clinical and radiographic findings included <findings> <findings> <findings> <findings> <findings> <findings> <TMJ> <Oral CA> ASSESMENT: <dx> <dx> <dx> <dx> <dx> <dx>PLAN: <secNV><secNV><secNV><secNV><secNV>Risks, benefits and alternatives have been discussed, <ptCares> <accepted> <Next Visit><secNV><secNV>
This is the simplest filled out note for someone who has no problems and no complaints.
If you don’t want to keep having to open a chart to access the note writing section you can instead go to the top of the main PracticeWorks window and pull down the “Expert” menu to “Automation Expert”> “Response”> “Notes”.
This will bring you to the box called “Note template definitions”.
Here you can pick a note to update by first selecting the note to edit and pressing “Edit template” or create a whole new note by clicking “Define new”.
This note has worked well in our office and the first variable looks like this:
The variable name “radioType” is already in use so it is dimmed out and cannot be accessed. The description is the actual question asked in the note you will be filling out. The multi-choice list is added with the various x-ray procedures done at your office and placed in the proper sequence from the beginning because the order cannot be altered without deleting the list first and re-entering it back into the right sequence.
I find this next variable useful for a few purposes and helps with radiograph quality control. This variable puts the person who took the x-rays in the note. This way if you get sloppy work consistently from one person, that person can be singled out to go through additional training. Plus they know their name is being put on the work they are doing and this may help them to do their best work each and every time.
Then of course it is wise to put the doctor’s name who is actually doing the exam and reviewing the x-rays.
Next comes the SUBJECTIVE part of the S.O.A.P. note. It begins with a simple “Check box” variable that states that the “Health history reviewed”. Then there is a long list of possible chief complaints in a “Multi-choice list” variable.
Listed in this button are the following chief complaints: prolonged sensitivity to cold, prolonged sensitivity to heat, sensitivity relieved by cold, percussion tender, sensitive to sweets, biting pain, spontaneous discomfort, throbbing pain, discomfort increased by head moving, gingiva feels swollen, points to tooth # , “nothing in particular.” (notice the period at the end), toothache at night, broken tooth, lost filling, facial swelling, lost crown/bridge, sensitivity to tooth brushing. Obviously you can add your our reasons and if you find a good one, tell me about it. Thanks!
Then I put at the end of the chief complaint section a “Check box” variable that says, “the pt. only wants an extraction.”. This is for the emergency appointment patient who only wants the tooth out.
The OBJECTIVE section of the note includes the finding of the actual exam. This is another long “Multi-choice list” variable.
This list grows all the time and includes: caries, periodontal disease, periapical pathosis, root tips, impacted tooth/teeth, over/underhang(s), vertical root fracture, supernumerary teeth, congenitally missing tooth/teeth, WNL, recurrent decay, exfoliating deciduous teeth, calculus, ineffective oral hygiene, broken tooth/theeth, open contact(s), deciduous tooth remnant(s), failing endo, possible bone pathology, supra-eruption, lost crown, toothache, facial swelling, lost filling, chipped tooth/teeth, broken filling(s), non-restorable, abfraction lesion(s), heavy tobacco stain, black hairy tongue, pericornitis, fractured cusp(s), abscess, parulus, irreversible pulpitis, reversible pulpitis, non-vital tooth, cracked tooth, gingivitis, candidiasis, herpes simplex type 1, and of course you can add or subtract as you see fit.
I do a head/neck exam and note the TMJ status and to check for cancer.
The ASSESSMENT part of the note is next and is where I put the patient’s diagnosis:
Listed in this “MUlti-choice” variable include: dental caries, periodontal disease, malocclusion, herpetic gingivostomatitis, irreversible pulpitis, periapical pathosis, WNL, necrotic tooth, non-restorable tooth, recurrent decay, broken tooth, cracked tooth, and this list is short because if it is something that is different than these it can be added with the cursor in more detail.
The PLAN is next and this is where I got a little lazy and just put the list of “Other Next visit” variable in this spot (this was written in the blog “How to Write PracticeWorks Dental Notes: Local Anesthetics”). The only problem is that the first thing on the plan starts with a comma and will have to be deleted each time you write a note (or not ;-)).
The next thing I like to place into the note is if the patient is interested in having routine care.
And it is also a good idea to make a note ti if the patient accepted or rejected the treatment plan.
To finish this very important note I put at the end the “Next visit:” and “Other next visit:” noted as seen in the other above written notes.
Now, didn’t forget to make the “Define Autolinks” in the “Exam” button:
It is already in my list, but we will pretend it is not really there by adding it again. Press the “Add” button.
Select the “X-ray/Exam Note” and press “OK”.
Press “YES, …”.
Sequence the “Add note X-ray/Exam Note to chart” to the top of the list by adjusting the numbers in the right hand column.
Now when you push the “Exam” button under the group heading “General” it will first ask you which exam you did (SEE the blog “How to Link Procedure Codes to Buttons in Kodak PracticeWorks”) and then it will ask you what kind of x-rays you took and to fill out the “X-ray/Exam” note. No more forgetting!
This is how the noted comes out and with a little tweaking it will look just right:
Full Mouth X-rays taken today by Dawn with a lead apron and were reviewed by Dr. Mark Kraver.
SUBJECTIVE: Reviewed health history, Chief complaints include points to tooth #1, prolonged sensitivity to cold, percussion tender, biting pain, spontaneous discomfort, the pt. only wants an extraction.
OBJECTIVE: Clinical and radiographic findings included caries, periodontal disease, periapical pathosis, toothache, irreversable pulpitis, non-restorable, asymptomatic TMJ clicking/popping, Oral Cancer screening WNL,
ASSESMENT: dental caries, periodontal disease, irreversible pulpitis, perioapical lesion, non-restorable tooth,
PLAN: Extraction(#1), Cleaning/Comp exam/FMX
Risks, benefits and alternatives have been discussed, request not to have routine care, Treatment plan accepted. Next Visit: Extraction