The problem-oriented dental record was developed forty years ago for the purpose of facilitating and organizing the care of the patient in order to optimize the outcome of the patient through a thorough management of all problems and conditions. The core of this approach is through the problem list from which a rational treatment plan can be constructed.
The record is divided into six sections. Data are collected through history taking, physical examination, and radiographic evaluation and entered into the appropriate section. The data collection sections are constructed so that a longitudinal assessment can be made regarding problems in terms of time. If there is no change in a specific problem, it might be considered a condition to watch rather than to treat. The classic example is enamel caries. If it does not progress, it should not be treated.
1. DENTAL HEALTH HISTORY
The school-based clinics and the community clinics utilize different health histories. The dentist must review these forms and use these forms as the basis for querying the patient/parent/guardian regarding all positive findings.
MEDICAL HISTORY STATUS – INITIAL AND UPDATES
Comments must be written for each examination. The dentist must date and sign each entry. If there are no pertinent positive findings, the dentist can summarize this by writing “stable”, WNL, or anything indicating that there has been dialogue regarding the health of the patient.
All chronic prescribed and over-the-counter medications must be listed with the daily dosage and reason for each medication. This shoul5/30/07aken, write “none’.
Record all radiographs taken.
2. CLINICAL EXAMINATION
All information on this section must be filled out.
SOFT TISSUE EVALUATION
Examine all areas noted on the form. If an area is normal, place a check in the box under the heading WNL (within normal limits). If any area deviates from the norm, place a check in the box under the heading Abnormal and describe all findings in the Comments section.
GROWTH, DEVELOPMENT, AND OCCLUSION ANALYSIS
Assess the occlusion utilizing Angle’s Classification. Use the molar relationship as a guide. If a molar is missing, use the cuspid relationship. Use the periodontal probe to determine the overjet and open bite. List all teeth in crossbite and note the midline. Note all habits. For assessing the tongue thrust, have the patient articulate an “S” sound. Ask the patient to say “mi casa, su casa”. Note all problems in the Comments section.
COMMENTS ON GINGIVAL STATUS
Comment on the health status of the gingival. Note all problems and inflamed areas. Check the pockets at assess if there is any periodontal disease. If any pocket is 5 mm. or greater, use the periodontal chart for a complete assessment of the periodontal status.
CLINICAL EXAMINATION UPDATES
During each recall examination, complete a clinical examination with comments on all positive findings.
3. DENTAL CHART
This form replaces the traditional tooth symbol charting system and is designed in a spreadsheet format to provide a longitudin5/30/07the teeth. This format allows for one initial examination and four or more periodic examinations. Each maintenance charting can be used for two entries. This is done in the cases when there is no change in the patient’s oral health status during the subsequent charting.
The charting utilizes codes for existing conditions and problems and provides the capability of documenting a wide range of conditions and problems. The list of codes is found at the bottom of the chart.
This reflects the state of the teeth at the onset of treatment. The codes list the most common conditions. Conditions not given a code can be written on the form opposite the tooth number. The steps are:
A problem relates to any abnormal or pathological finding. The list of codes includes the most common of these problems. The identificatio5/30/07– list the problem code and place a dash if a surface is required, e.g., NC-D (new caries-distal surface). Please note that only surfaces where there is pathology should be noted. It is common for dentists to list DO when the caries exists on the distal.
Degrees of severity are identified by the codes S and W. S indicates the problem is “severe” and requires immediate treatment. W stands for “watch” and identifies incipient problems not requiring immediate treatment but ongoing surveillance. Examples of this are enamel caries and overhanging margins less than 1 mm. These codes are placed next to the problem code, e.g., PAPS, and next to the surface it pertains to e.g., NC-MW. If the same problem affects multiple surfaces, than the code indicating the degree of severity is placed next to the surface separated by the slash, e.g., NC-MS/FW.
TREATMENT AND DATE
All completed services for each tooth are written in this column using the same codes as the Existing Condition codes plus the code EXT indicating an extraction. Commas are used to indicate two or more services. The date is placed when all services are completed for each tooth, e.g., RCT, C-O-6/20/03. This column updates the existing conditions.
Complete this using the problem codes and treatment codes as used in the Initial Exam. Each new treatment phase updates the existing conditions. If no new problems are identified during a subsequent maintenance exam, use the same column and note the date and examiner at the top of the column.
4. PERIODONTAL CHART
This chart should be used only in patients with periodontal problems, generally defined as at least one 5 mm pocket or obvious vertical bone loss. The steps are:
5. PROBLEM LIST/TREATMENT PLAN
The Problem List lists a complete set of problems noted during the examination of each patient and serves as a profile of positive findings. The listing of problems facilitates a more comprehensive and logical treatment plan. Problems reflect conditions that impact negatively upon the patient and require either treatment or ongoing monitoring. NEEDS such as a root canal treatment or a restoration are NOT considered problems but services to correct a problem.
The problem list is that – a list of all problems related to the oral region – and not a list of teeth with problems. This gives the dentist a view of the patient much akin to that as the physician views a patient. This list is completed first by listing the problem and then the area and teeth involved. Each problem should be separated by the degree of severity, e.g., severe caries, caries, incipient caries. This will assist the dentist in prioritizing care. Examples of problems are as follows:
The order of problems is not important. What is important is the inclusion of all problems so that the dentist can view the patient in his/her entirety so as to construct the most meaningful treatment plan.
The treatment plan requires the dentist to identify all needed services, to prioritize these services based urgency, and to develop a plan for multiple appointments. All these variables can be easily worked out in a single treatment with few problems. Patients with multiple problems often require two lists. One is to identify the services needed and a second to prioritize services and determine the sequence of visits. In complicated cases, it may be necessary to not provide a complete treatment plan but to provide an initial set of services followed by a reassessment of the patient’s status before completing all the patient’s needs. You will find that the original plan can be modified greatly as a result of the initial treatment.
6. PROGRESS NOTES
Progress notes should be short, concise, and legible with all necessary data and information included. Each note must include: