* Final Exam Material *

Record keeping & Treatment Planning

Gazalla AlGali
Eliyan Ababneh & Ahmad Fouzi

28 7 2015
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 Record keeping& treatment planning

Record keeping includes patients number in the country, if he has medical card,
patients name, age, and address. The receptionist should give the patient a sheet to fill
these things. You have to pay attention to this lecture because it is very important for
every patient to have his file complete. Otherwise, there will be deficiency in the
documentation and then there will be no enough information for your patient either at
the time of your exam (in the clinics 4th and 5th year) or in the future for his own oral
health care.
These are files. The system is different in different parts of the world.
Sometimes you have to file like this

And sometimes it is computerized (soft

Copy)
So you are going to work according to
The system in your country.

Lectures outline

Record keeping
Definition, importance of record keeping
Record keeping for pediatric patients at JUST (how to fill these records
completely)
Components of dental record
Consent form
Dental exam sheet (the most important for us)
Medical history sheet
Extension sheet (whatever you have done for the patient)
Trauma sheet
Diet sheet (especially for the first visit of the patient)
Radiographic record
Photographic records and stone models
Cephalometric tracing sheet (if the patient has an ortho problem)

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 Treatment planning
Which is the most important thing for us..we have to make a treatment plan for
our patientsfor emergency we make a short term treatment plan long term
treatment plan, and review
Treatment planning exercises

Definition

The dental chart is a permanent record (we call it permanent because

everybody should have one in the treatment) of a patient's dental care
including dental history,medical history, trauma, tooth abnormalities,
radiographic findings, periodontal examination, proposed, actual, declined,
and future treatment plans, as well as home care instructions. Everything
should be included.

NOTE: In the clinics, record keeping will be evaluated by 10 marks for the
assessment of every patient

Recording the condition of all teeth, as well as soft and hard tissues, is
necessary to provide quality care. The charting of existing conditions provides
basic information for an accurate, comprehensive treatment plan. Otherwise,
you can't make a good treatment plan for your patient.

To reach these points you have to conduct a thorough clinical examination.

There is a very easy way to examine your patient by using these instruments
(which are available for every dentist); dental probe, tweezers, explorer,
dental mirror, etc.
Excellent lighting, magnification, and dry cleaned teeth are also necessary to
clinically evaluate the oral cavity.So, this is the first line of examining the
teeth
There are some aids we can use if we can't see clinically to discover the
decay, for example, if it is proximal and you can't see it then you can use

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 other ways such as having an x-ray for the tooth. There are other aids as
well!

Dental History (important)

Is it the first time for your patient in the clinic or he has had previous
visits? And if he has had previous visits then what is the treatment that has
been done for him? (For example, extraction). What is the patient's diet?
What is the client doing for home dental care?He maybe had some
pigmentation previously.
It is very good for the assessment of child's behavior and in complete
treatment plan for your patient.
There are things special for pediatric patients that we've taken with
Dr.Mawyah, such as the body weight (if his weight is okay for the child's age)
, the shape of the skull if it is normal or abnormal (brachycephalic-flat
faced, mesaticephalic+-medium faced, dolichocephalic-long nosed), growth of
the child if it is normal or abnormal especially loss of dentition or even from
impaction stage, occlusion abnormalities, plaque and calculus, tooth
abnormalities.
Is your child mentally normal or not? Sometimes we have handicapped
patients. We can notice from the first sight if the patient is mentally normal
or not and we have to refer those patients to another specialty so they can
take their cases.
These dental records should include radiographic findings. The things your
patient can't read in the radiograph. Is there any trauma? Root fracture, bone
fracture, inter-ridiculer changesetc?
Periodontal abnormalities including inflammation (bleeding on probing),
gingival edema, periodontal pocket depths, attachment loss, gingival
recession or hyperplasia, furcation involvement, mobility, proposed/declined
treatment, actual treatment, future treatment plans, and home care
instructions including proposed re-exam appointments. all should be
included
(TOO MUCH, I KNOW!! @_@)

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 Benefits of Dental Charting

Keep an organized and easy to read record of the state of the patient's
mouth. Everybody can read it. It is unified as well meaning that every
dentist can understand it all over the world
They can refer back to this chart at future visits and update it to keep an
accurate record of what is happening in the patient's mouth. Whatever
you need in an emergency case you have to write it. Everything should be
written including the long term treatment plan and the short term
treatment plan, thenyou review your case.
The benefit of having a dental chart, made and updated, is that the
dentist is able to keep a good record of the health issues. This means that
he/she can give you the best care possible and track progress if patient
has issues that require care or treatment.

The chart gives both patient and the dentist a point of reference so you can see if
you are making improvements in the dental health. If any dentist did anything for
your patient then it will be written there.

To track update, update for children is different than adults because they
are in development stages. The pediatric patient may come with primary
dentition stage then after 2 or 3 years he will come with mixed dentition
stage. So, there should be different stages in our treatment plan because
he has permanent teeth at the second visit, for example.

Importance of Record Keeping

Continuation of dental care (by other dentists)

Medico-legal issues
Teaching and research
Forensic issues

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 Continuation of dental care:dental records assist in efficient and
complete delivery of care in case if the dentist is changed.
Records keep you assessing the treatment done for the patient; e.g., last visit
you excavate caries and put dressing material, you can assess the success of
your treatment.
Or if you have done apexification you will assess the root development.
In case if the patient changes his dentist for any reason, the new dentist can
continue the treatment according to the record.

Medico-legal issues:if there is any compliant from the patient, this record,
which is written by scientific manner, will protect you.

Teaching and research:Medical and dental records will help in clinical

studies of the different real cases for the purpose of teaching, education, and
research.

High quality care: facilitating high quality, comprehensive care by making

detailed and relevant patient information readily-available to treating dental
care providers, if there is no individual records for the many patients who
attend daily, it will not be possible to remember the medical problems, e.g. for
each patient.
So we need to document for each patient the medical history, in our example,
in order to manage this problem and to prevent any problem that may happen
later on during the treatment.

Forensic issues:in situations of war ,for example, they can use these records
as reference for dead patients to recognize them.

How long do we keep patients records?

Depends on laws and regulations of the country.

Ideally (general rule): For adults 7 years after final entry.For children
records are kept until age of 25 year.

First examination of child patient should be when the first teeth erupt
(lower central incisors) at 6 months to 1 year, it can be repeated every 6
months or according to caries risk, (Mc Donald 9th edition).
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 Do not forget:

It is our duty to keep patients information confidential. Your patient trusts you
with his private details and has every right that you respect the confidentiality

of the information given.

How is the information recorded?

Entries must be made in chronological (time) order and should be in

sequence.
First visit is for emergency or for whatever the patient needs. Sometimes we
need to start with very simple things depend in patient cooperation.
Sometimes we need to start with another appointment to finish caries/ or
the patient has pain! Plz check the accuracy for the last sentence in the record
(16:08).
So we have to make a compromise between these things; when should I start and what
things should I do, Do I finish in first visit or do I have another visits?

They should be accurate, concise, and promptly retrieved when

required (you can easily go to the chart and select the information you want
such as medical history).
to achieve this you should know the important information that is worth
recording,
Also how to record it, and how to order it and save it.

When is the information recorded?

Immediately at the time of appointment, or soon after "due to you have emergency
cases or whatever " because we may forget the needed details. DON'T POSTPONE
IT

Uniform dental recording

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Many different tooth charting systems are currently in use. Differs from country to
country

Here are 2 examples:

A. The universal system, in Indiana University

B. JUST Dental record form.

Indiana University

This is the first page

This is the second page

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 JUST dental record form

You have to read it and understand it

The first page

The second page

Photographic record and stone models:

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 Some times we need photographs Either intraoral or extra oral according to the
case.Photographs taken should be in CD and files, you should indicate it in the
chart that photos are taken, also indicate size and type, e.g.4x EO OR 5x IO.

Sometimes we need to take an impression as well, if we need space analysis for

example. Alginate impression is poured and trimmed, and stored in a safe place for
the patient.

Trauma sheet

If a patient has trauma like this there is a special form and it is available.you have
to recommend this case according to the findings of your case. It should be
included in the report. Diagnosis, investigations, everything about the case!

This is page aThis is page B

They use FDI system

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We put everything we find. For example, in this case(the picture above) we have a
class II and soft tissue injury as well, we are going to give him antibiotic
because of the soft tissue injury so we write that down.
Whatever you are going to do for the patient, whatever restorations you are going
to do, you write it down.

Follow up: if the tooth is mobile for example then you have to treat it
You have to write that you've done some splint?? for the patient. It should be for
7 days or whatever according to the case . Plz check 21:48

School excuse form:

Now, sometimes the children are very whiney..

why? Because they need to go to school. There is an
excuse for them in the clinic. It is available and
you fill it in Arabic, it should be signed and stamped
and given to the patient to take it to school. Even if
the child has an exam day then he can repeat the exam.

Keep a copy of it in the child's file.

This is a form for the medical information of the
Child. Sometimes, the parents have to fill it in the Plz check the slide #23
Reception even the children can do it as well and to see the medical
Discuss it with the parents later on. history form clearly
This form also should be included in the child's report

Referral form

It is available and we have 2 forms; one for postgraduates and one for
undergraduates. You can use whatever is available because the doctor thinks the
forms of undergrads are not present any more.
You have to write if your child, for example, needs pulpectomy and you can't do it
then send him to a postgrad student to do it.
If the child needs endo for his lower 6 or if he has malocclusion then you refer him
The form should be signed and the date should be there.
Referral form should be included in the patient's record as well.

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 Laboratory form

If you need an impression for the patient for example.

There are online forms.
You can fill them with whatever you need; material,
shade,.etc
For example, if you need a space maintainer for the
Patient then you have to write the type of space
maintainer, material used, and when you have to receive
this space maintainer. All of these are available in this
form as well.

Cephalometric tracing and record form

If your patient has ortho problems. At the beginning you

have to brace them. A postgrad student can do it and
then you can continue your treatment.
You include it in the patient's file.

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 Consent form

This is really important for every dentist. You have to keep it in the child's file.
This will protect you especially ids the patient has medical problems or if you
are treating your patient under general anesthesia.
In some countries, you can find a lot of consent forms for the extraction of a tooth.
Another forms are for extraction of 2 teeth. It should be signature before
extraction.
If your patient is admitted for treatment under GA there should be a consent form
as well.
Consent form is really helpful for the dentist as well as the patient legally. It
protects the dentist if anything goes wrong during the treatment. This form will
protect you.
This is an example of a consent form

Consent Form: for history, treatment, GA etc.

I, _______________________, have been informed by ____________________

(Patients name) (Dentists name)

as to the treatment to be performed: [description of treatment]. I have also been informed of

the risks associated with this treatment and any alternate procedures [can be listed on the
form] that could be performed instead of this treatment. _______________________ has
also (Dentists name)

Explained the risks associated with refusing this treatment. [can be listed on the form]

Health History Disclaimer.

I certify that I have read and understand the above information. I acknowledge that I have
answered the above questions correctly and to the best of my ability and that any questions
that I may have had have been answered to my satisfaction. I will not hold my dentist or any
member of his/her staff responsible for any errors or omissions that I may have made in the
completion of this form.

Patients Signature Date

Dentists Signatur
e Date

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 Sometimes, for the history itself there is a consent form.
To make sure that the patient can understand all the information given during the
history taking and knows everything from the beginning so that there will be no
complains.
And don't forget that in the Arab world any mistake can cost the dentist hundreds
and thousands!! $$$ @_@
For example, if the patient has a medical history and she did not mention it and
you discover that the patient epilepsy, for example, and she had an attack in the
chair then there will be no complains for you. You are complaining this time.
But if she mentioned it during medical history and it is written then you'll be held
responsible.
Next year we are going to have 2 cases of these so it will be an experience for every
dentist.

Radiographic prescription

When do we prescribe radiographs for our patients?

Is every patient candidate for x-rays?
There are special cases where we need to prescribe radiographs. So our aim isto
obtain maximum amount of information from the selected x-ray (bitewing,
periapical,..etc) and less radiation. These are the most important things espically in
children and pregnant ladies.
AGAIN: Maximum amount of information
Minimum amount of ionizing radiation.
This is the radiographic form for the x-ray of your patient.
You have to write the patient's name, D.O.B, file number, medical history (if he is
normal you have to write: nothing of significance or he is well and not ill)
If it was a female is she pregnant or not
If the recommended x-ray is intraoral
Or extraoral bitewing, periapical,
Or occlusal.
Finally, your name and date
Send your patient to the radiographic
Department until he gets his x-ray and
then he'll get back to you with the x-ray.

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 It is really important to recall whatever you have seen and read it. It should not be
underestimated neither overestimated.()
It is not easy to remember what you have seen this is why it is very important for
you to write it down.
The value of radiographs as a part of the integral records of a patient cannot be
overstated.
Good radiograph is difficult to match with written records and the radiograph is
more indisputable (true) than a written statement in a court of law provided the
name of the patient is indicated as well as the date.
However, this is not a call to expose the patient to ionizing radiation merely for the
sake of documentation.
If your patient is free of decay and proximally there is no contact then you can
examine him clinically, there is no need for x-ray
If there is a good contact proximally then we can't see the area therefore we have to
take a radiograph.
So, it depends on the case you are working on
One may not retake radiographs for the sake of improving one's grades because this
will lead to over exposure of the patient to ionizing radiation. Radiographs legally
must be kept for at least 5 years; some authorities state 7 years. Dr. Ghazaleh
keeps it forever.

Documentation (important)
Clear medico-legal requirement for documentation of interpretation (interpretation
means how to read the x-ray and information from the radiographs).
Signed and dated radiographic report must be written with patient's record.(this is
important for kids just for follow up issues)
Clinically useful in treatment planning and case presentation.

This is the radiographic form used in JUST

Remember that we useFDI system
-You have to mention the number of the tooth
and the changes that happened to it.

-e.g. if there is periapical involvement then

mention that tooth 55 has periapical changes or
bifurcation involvement

-e.g. tooth 85 has root resorption...you write it

down and write if it is physiological or
pathological. Other findings.like trauma or a
cyst or odontome and any other thing 14 | P a g e
**P.S. this part contains many pictures so be careful when reading what is about
them coz it is very imp.

Diet Sheet
After following all the requirements
regarding the radiographs we move to the
next step which is diet sheet
- Diet sheet: this sheet is done by pediatric
dentists for each child and let his parents
fill it for a period of time usually 3 days
why???
So we can know what the child eats and
what is his diet also sugar frequency rate in
order to determine if it is good or bad diet
and if there is any deficiency so it can be fixed or totally change it.

Charting.

They contain both permanent

and primary teeth in them.

Charting: filling in the chart with what

is the condition of each tooth and it is
very significant due to:
1. Baseline data it is done at the
beginning and it is part of the
initial examination, you should
examine the patient mentally
physically and include this in the way.
2. Resource of treatment planning

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 3. It guides the use and direction of instrumentation
alerting the clinician to complex pocketing, mobility, and root
furcation involvement.
4. Never ever forget to update charts evaluate the success of home
care and professional treatment
like if the patient has an already done chart u must re-do it coz 99.9% of
times there could be changes and some teeth could be restored.
5. Further uses for charting are as legal evidence (Some cases and
some parents can be unsatisfied of what you are going to present for them
so they might go to courts), to support a diagnosis and justify
treatment, and as forensic evidence. The best defense in a
malpractice suit is complete and accurate documentation.

** according to charting in our school we only use FDI notation system not
other systems and thats not haphazardly in both primary and permanent teeth in
pediatric clinic due to many reasons such as:

1. Simplicity and ability to be understandable

2. Easy in pronouncing and in conversation
3. Readily communicable in print and by wire
4. Easy to write on PC
5. Easily adaptable to standard charts used in general practice.
Can be read by all other dental practicenior regardless of their
specialists

**After we finish the charting we move to the next step which is

Diagnosis

In this step we diagnose according to the problem or problems we find

- write the problems with short scientific understandable words
- ex:Mo 16 = mesio occlusal careis on the upper right 1st molar
So we have several spaces numbered from 1 to 10 for examination we must
fill each problem we find like:
1. caries; on which tooth, location and how many teeth involved
2. crown; fractured, need one , reparable
3. gingivitis; chronic , localized ,sever , normal
4. occlusion; malocclusion, overbite, over jet

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 If you have a new patient and it is his first visit what u should do???????
- (the principles of treatment planning):
You should start from the beginning by making medical and dental
history ---- dental examination ---- management of the problems u
will find ---- radiographs (the principles of treatment planning)
Then you must work in phases and they are 5 cases (treatment plan):
1. emergency phase: first visit and include dealing with what u find in front
of u as emergence case such as swelling, sever pain, fracture or bleeding
(anything indicating emergency)
2. preventive phase: second visit include prevent decay, analyze the child and
parents , oral hygiene instructions
3. Corrective phase: third visit and the most visit full of work and can be in
several sub visit as well contains restorative/endodontic/surgical
treatment/ inspective or preventive orthodontic/ space maintenance.
4. maintenance phase: where in some cases you need to fix something more
than u did in the 3rd phase
5. recall phase: to check that everything and all your work is ok with no
problems and there is a good response for the treatment

Now more in details about each visit and the treatment planning:

1st visit:
Usually for new patients which you didnt work with or treat and mainly with no
pain or major procedures include: history and examination mainly
//management of acute problems//Radiographs, // aims of treatment
explanation to parents

// emphasizing the need for preventive and restorative treatment // giving

an estimate number of visits for the parents to know how to deal with it,
perform simple procedures: apply prophylaxis only to the ant teeth, //
topical fluoride application, // excavation and ZOE filling

2nd visit:
The preventive visit the work here is still minor but more advanced than the first
visit and include: topical fluoride application, // fissure sealant/preventive

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resin restoration- oral prophylaxis // design the plan of treatment depend on
patient need, // educate and motivate the parents

3rd visit:
All heavy work is done here include: introduction of the
child to the main treatment procedures, // restorative
dentistry: amalgam or composite or GI restoration.
Normal restoration
4th visit:
Called subsequent visit means in here we do the
aggressive and complex treatment such as extraction/
endo- treatment/ stainless steel crown/ orthodontic treatment. (Usually
this visit is considered under the 3rd phase).

**Endo treatment before and after on the

lower 7.

**Stainless steel crowns

**All what has mentioned before was a one way of treatment planning**

) )

*** Quadrant dentistry or quadrant method ***

It is an alternative way of treatment planning but remember doesn't work

for all patient due to time issue coz maximum time for a child on the chair is
30 min beyond that he will lose his concentration and discipline and become
uncooperative, so use this method with cooperative children only

How to do quadrant method?

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**The whole quadrant is isolated by a rubber dam and all the working that
quadrant is done in a single visit usually we start by upper right then upper left
then lower left then lower right (clockwise)

This method has got many advantages including:

1. reduce number of appointments so instead of working on 1 or 2 or 3 teeth
u work on a whole quadrant
2. makes maximum use of time available so no time is wasted
3. very beneficial economically for the parents

There are some issues that face us as a dentist when working with children
and they are:
1. the child: decrease of his ability to cope with the treatment; meaning
that the child can be uncooperative u must deal with him and try to make
him cooperative unless refer him to specialist that know how to deal with
him (((((((((((((( v.imp u r not allowed in the clinic to deal with children
below the age of 6 years old due to cooperation that they offer )))))))))))))))
so your age of child is from 6 to 14 and even if u face any problem refer it to
specialist
2. Parents: sometimes the parents can't control the intake of cariogenic
foods and drinks.
Parents themselves are careless and uncooperative with u even they can be
bad influence on the child or be bad with child it depends

3. dentist: like us as students sometimes we lack the training and the

experience in pediatric dentistry;
lack of dealing deal with any situation unless we already faced it before

Intervention of caries = your working the 4th year

- First: in the first semester of the 4th year you will not work with hand piece
you will do few things such as lowering number of microorganisms in
the child mouth by maintaining good oral hygiene and fluoride application
- Second: diet counseling you must reach the maximum perfect diet
between you and the parents.
- Oral hygiene maintenance.

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 - Fluoride.
- you should do regular dental care
- Education the family and education of the child make dental
appointment interested.

V.imp thing is the dietary guidance and it is done in this stage to avoid
bigger problems consist of:
1. reduce sweets and sticky food and snacks
2. avoid in between meals (so much important)
3. Promote non- cariogenic snacks.
e.g. - salads/dairy products.
4. End every meal with a fruit or raw vegetables.
eat a lot of vegetables and fruits
5. increase any fibrous diet source

All of this to reach healthy teeth for the child

((((((((((((If you want marks in the next year read this carefully I dont know if
there will be questions about it but read it
;)))))))))))))))

1. extension sheet: this sheet is the master key so

they count your case that you worked it include all
details u collect about the patient, the date, chief
complaint, medical history, dental history, the
treatment that u did, patient behavior and
cooperative, next visit procedure

P.s (never to forget to sign it from a supervisor)

the assessment sheet markssssssss (HISTORY, EXAMINATION,

RADIOGRAPHIC REPORT, DIAGNOSIS AND TREATMENT PLANNING)
0_O

After each clinic u will be marked

directly according to your work and
this form is how u going to get
marked you write the name of the

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patient then in each column u will be marked of 10 so your mark will be for each
case from 50.

p.s dont forget the clinic is 3 hours the last 15 min is for you and your
partner to clean the unit and do disinfection and write the file of the
patient to get marked and at least one partner must know how to speak
Arabic no 2 Malaysian are allowed to be together to facilitate dealing with
the child and his parents.

Requirements are as mentioned in the pic

2 fissure sealant, 2 PRR, at least 1 ART

More requirements:

2 oral hygiene instructions one written and

the other is demonstration for both child and
his parents, 2 diet advices on 2 different
patients, 2 scaling and prophylaxis and gel
aplcation/ and 2 extraction at least but can be
more

P.S.: each one of these requirements is out of

10 and the infection control is out of 10
without infection control u will get half the
mark like if u got 8 of 10 in the fissure sealant
and 0 out of 10 in infection control your mark will be 8 out of 20 be careful.

***Now we will move to 2 exercises the doctor did solve that represent your steps
of working in the next year inshalla.

Follow these steps with the pics:

1. meeting the patient and talk to him or his

parents to know his chief complaint and start
by oral examination and here it was that the

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 71-81 are retentive which mean they didnt replaced by permanent

2. take radiographs for the patient depend on

what u need and here we will take bitweng
radiograph for both right and left

3. fill the clinic form by starting in this consequence

Plzzzz read the paper or at least see it to know what we are talking about

(patient's name address- date- patients

date of birth height weight
accompanied by whom chief complaint-
medical history dental history social
and family history favorite school subject
avg in school- type of house siblings-
dads occupation- moms occupation- the
extra oral examination; if there was no
problem write either normal or no
intraoral examination periodontal issues
Occlusal analysis; specially to write the
angle with shifting with overbite and over
jet {over jet normally = 2-3mm / overbite =
25-30%} fill the dental charting as we
studied before the radiograph that u has
taken and what is the things u find on it if
there was any problems finally you write
the diagnosis of your main problem and
what other things u find ) .

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 the avg gives indication how smart is the student, the favorite subject can tell
you what the personality of the child, social and medical history of parents can
tell u a solution about the patients case
remember if it was normal or patient
didnt face any problems either right
normal or no

4. the quadrant therapy or the visits list

we fill it each visit we finish what is
done and on what tooth and if there
was anything that need referral we
refer it just like that (we are not
allowed to do pulpatomy or stainless
steel crown it is for 5th year students ) after you finish it you sign it and let
the supervisor sign it and then u are finished and will be marked

By this the Dr finished the lecture and she

gave us a case that you should read it is from
the slides simply as the previous one but full
of things so just check it up I will put it in the
next paper

The end
Have a good study it is easy lec and full of general info rather than specific one

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