Lesson 1 – Charting Your Course Part A. Course! YOUR Charting.
DENTAL CHARTING
description
Transcript of DENTAL CHARTING
DENTAL CHARTING
Dental Records provide descriptions & assessmentsof the patient’s medical and dental status
Medical History Forms provide the medical information
Dental charts provide the oral conditions, assessment and prognosis for dental treatment
Dental Records are conducted to record the Dental conditions present in the oral cavity and treatment needed.
It is part of the legal record
Dental records are preformed at the initial examinationand every subsequent visit.
Uses of these dental records include:•DIAGNOSIS•CONSULTATION•BILLING•FORSENSIC DENTISTRY IDENTIFICATION
The Oral Examination used to record the dental historyConsists of the following:
•VISUAL EXAMINATION•PALPATION•CLINICAL EXTRAORAL EXAMINATION• Face, neck• Lymph Nodes• TMJ• Lips
•CLINICAL INTRAORAL EXAMINATION• Soft Tissue Exam
• Oral mucosa and frenums• Tongue• Palate• Uvula• Floor of mouth
• Hard Tissue Exam of teeth• Periodontal Charting (next semester)
• Perio pocket readings• Gum levels
•RADIOGRAPHS•INTRAORAL IMAGING•PHOTOS
Armamentarium (set up) for oral examination for charting
MirrorExplorerAir Water syringePeriodontal probeBlack ink penRed and Blue pencilCharting form or computer program2 x 2 gauze
There are several formats or styles of dental charts:
ANATOMICAL - teeth are outlined on their crown, root, occlusal mesial, distal, facial and lingual
GEOMETRIC – geometrical shapes like circles, triangular are representative of the tooth and surfaces
NUMERICAL – uses letters, symbols and codes to describe conditions
AUTOMATIC/COMPUTERIZE – Usually part of the dental office managementsoftware using a wand, voice activation or computer keyboard to chart conditions
Anatomical Chart completed
Example of a geometric chart system
COMPUTERIZED CHARTING
THE DENTAL CHART USES THE FOLLOWING FOR NOTATIONS:•Symbols Figure 28-11 in MDA
•Color Red needed; blue done
•Numbers
•Abbreviations – Next 4 slides
Mobility 0, 1, 2, 3 or I, II, III
Furcation I, II, III – the lost of attachment between bifurcated or trifurcated roots
COMMON DENTAL ABBREVIATIONS
TERM ABBREVIATIONAmalgam Am, Amal
Bonding Bd
Bridge Br, Bdg
Fixed Bridge F Bdg
Removable Bridge R Bdg
Buccal B
Calcium Hydroxide CaOH
Composite Comp
Denture DTR
DMF Decay, missing, filled index
Full upper denture FUDTR
Full lower denture FLDTR
Diagnosis Diag
Distal D
Emergency Treatment Emer RX
Examination Exam
Extraction Ext
Facial F
Fluoride fl2
Full Crown FC
TERM ABBREVIATION
Full veneer Crown FVC
Three quarter Crown ¾ Cr
Gold G
Gold Inlay GI
Home Care HC
Immediate Denture Immed Dtr
Incisal I
Labial LA
Lingual L
Mandibular Mand
Maxillary Max
Meisal M
COMMON DENTAL ABBREVIATIONS
TERM ABBREVIATION
Nitrous Oxide N2O
Occlusal O
Oral Diagnosis Treatment Plan ODTP
Oral Hygiene OH
Pontic Pont
Porcelain fused to metal PFM
Porcelain Jacket PJ
Post operative POT
Prophylaxis Prophy
Proximal Prox
Root Canal Treatment RCT
Study Model SM
Sealant SLT
Stainless steel crown SSC
TERM ABBREVIATION
Temporary Temp
Treatment Tr
X-ray x/r
Full mouth series FMX
Bitewing x-rays BW
Within normal limits WNL
Another anatomical chart completed with additional information
Review of classifications of cavities
Caries chart symbols
Oral Conditions Charting Symbols
Additional Charting Symbols of oral conditions
More charting Symbols of oral conditions
PRACTICE CHARTING CHARTING KEY
END OF SERIES