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Progress Notes: Written documentation of a patient’s visit is required within 48 hours of their appointment. Failing to do so will result in withholding of production due to being in breach of written agreement to maintain proper patient records. Each note should include 1) accurate date of service, 2) review of medical history (including COVID protocol declaration of negative for travel, social, medical risk factors of CV19), 3) chief complaint, 4) diagnosis, 5) review of any testing done (radiographs, pulp testing, intra-oral pictures), 6) treatment recommendation, 7) patient’s informed consent, 8) rationale for treatment, 9) details of treatment rendered including proper surgical notes, anesthesia, materials used, shade, etc., 10) patient’s next visit: procedure and time frame (ex: 3 month recare)
Endodontic Isolation: when doing endodontics, rubber dam isolation is required. If rubber is not possible, please refer to specialty.
Photography: We advise that all emergency, esthetic, rehabilitation, hygiene recall, and most restorative patients have intra-oral pictures as a key component to their electronic health record. It is among the most powerful ways to convey understanding and value to proposed treatment. *In the event you anticipate the photos to be of use for demonstration to other patients, obtain a photographic consent.
Eyewear: Eye protection is mandatory for all our patients receiving treatments that have the potential to cause injury or irritation to their eyes such as prophylaxis, high or low speed handpiece usage intraorally or extraorally (working on a prosthesis in your hand), irrigation, air water syringe, rubber dam, etc. When in doubt, please provide protective eyewear to your patient.
General Imaging: follow ADA guidelines that describe minimal risk (never have had a carious lesion or no restorations in the last 36 months with no evidence of periodontal disease) vs at risk patients. New Patient Low Risk - Panorex & 4 BW (selected PA’s where indicated), Low Risk Recall - 4 BW 18-36 month intervals, Pan every 7 years and PA’s as needed. NP Mod/High Risk - FMX, PAN and 4 vertical BW with select PA’s if pt has unerupted or malpositioned 3rd molars, Mod/High Risk Recall - 4 BW @ 6-12 month intervals, vert VW if any evidence of bone loss or h/o extensive dental tx along with select PA’s (i.e. implants, RCTs, perio disease).
Referrals: Whenever sending a patient to an in-house specialist or another DDS, it is imperative that the Specialty Referral Form is populated. These forms are kept at the front desk and also with the hygienist in some offices. The most important details are in communicating the plan you have and your expectations of evaluation or treatment you would like the specialist to carry out. Additionally, indicating whether or not the patient is expecting same day treatment or a consult only is imperative so all involved are aware of the time necessary.
Nitrous Oxide Guidelines: Nitrous Oxide anesthesia is widely used in the dental setting as a supplement to local anesthesia, intravenous medications, or as a stand alone modality to facilitate our patient's comfort and cooperation during a dental procedure. Due to our familiarity with Nitrous Oxide we can lose sight of best practices which need to be followed in order to use the anesthesia safely for both our patients and staff.
All equipment needs to be in proper working order. The valves and connections need to be free of leaks and connected properly.
Please review the medical history for any contraindications (ex: pregnancy) to the use of nitrous oxide.
Please ensure the nose piece is fit properly without air leaks and is connected to an active scavenger system.
The clinical care provider(dentist or hygienist)is responsible for titrating and administering the anesthesia. Please monitor the patient for changes in physiological symptoms to determine if the dosing is appropriate. This is not the job of your dental assistant.
Please pay special attention to the volume of the Nitrous Oxide/Oxygen. If the bag is over inflated, you are delivering nitrous oxide into the room air. If the bag is empty the patient will struggle to breathe. You should have the volume titrated so you can see the bag inflate and deflate properly.
If you need to leave a stable patient currently receiving nitrous oxide, you must have a staff member remain in the room with the patient. The staff member cannot alter the dosing of nitrous oxide. The staff member should not be conversing with the patient. The patient receiving nitrous oxide should be breathing in and out through their nose when not open for the clinician to render treatment. Talking or exhaling through the mouth can potentially deliver nitrous oxide into the room air.
At the conclusion of the procedure, place the patient on 100% oxygen for 5 minutes. A staff member may monitor the patient at this time and remove the nasal hood when the time is up.
The clinical care provider must assess the patient personally to confirm that they have recovered from the anesthesia and they are safe to be dismissed. The clinician or staff member can then escort the patient to the front desk.
Clinical notes must reflect that nitrous oxide was administered, what percentage was used, duration of use, and that the patient received 100% O2 for 5 minutes pre and post op.
Unintended Outcome: in the event of an unintended outcome such as an instrument separation, retained root during extraction, patient dissatifaction with esthetic outcome just to name a few - please call your CDO for guidance. Dr Michael Fleischer (Senior Clinical Advisor) will also be notified.
Procedural Imaging: To maintain the integrity of our procedural record-keeping for billing and quality assurance purposes, we have found it necessary to require the following:
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