We move now to step 2: The Examination (Chair Side Forms). All dentists know how to complete an examination so it is not necessary to go into that, except to remind the reader that there are only two types of consultations for new patients according to the ADA’s CDT codes. Keeping this in mind makes things simple and allow for easy standardization in the practice.
(My previous post in this series dealt with patient intake using exciting new software tools. Summary: Look for a system that saves time and has a Pre-Clinical Workup System.)
- Limited oral evaluation – problem focused – D0140
- Comprehensive oral evaluation – D0150, D0160 (extensive), D0180 (comprehensive periodontal, D0145 (child under 3))
Examination findings should be entered into software forms either during or after the examination depending on the situation and habits of the clinician. The process should be simple and most (but not all) current practice management software will have an examination form available.
But, as we did when considering Patient Intake, let’s look deeper into the process of completing a dental examination form by asking the question – “What does one typically have after completing an examination form?”
The answer is the dead-data found in the static form. It’s no wonder dentists do not like completing computer forms. The reward for doing it is minimal.
What would make this better?
Recommendation: Use a form that responds to the user input. These responses should automatically populate the patient record with professional documents, create communications to patients and colleagues and even begin treatment plans.
Here are the attributes of modern software that should occur after simply submitting the examination form:
Submission of an examination form should automatically create multiple documents:
- Examination Report that is more than just regurgitation of a the form. The organization of the document should be systematically organized and useful for anyone reading the record.
- Clinical Findings Report for the patient that describes your findings in language they can understand.
- Letter to Colleagues reporting your findings.
- Problem List generated by the form input to insure resolution in treatment planning.
- Referral Thank You Letter that includes a review of the medical history, examination report and plans.
- Auto-Populate the Treatment Plan based on preferences of the practice. Examples: Anyone with xerostomia is prescribed a mouth rinse; anyone in orthodontic care is placed on fluoride home rinse; children within a certain age should automatically have sealants planned on unrestored teeth. The form software should allow the clinician to prescribe these choices. It saves time and makes sure the practice standard is offered at all times.
- Patient Education Documents. Specified examination form input adds these documents accompany treatment plans. Examples: Patients with findings that suggest the need for antibiotic prophylaxis should have information already added to the record for printing or emailing regarding the reasons for this. Patients with unstable diabetes should have information created regarding the preventive steps to ensure they are not prone to hypoglycemia during their appointments. Patients with anxiety requiring premedication should have created automatically information on management of that requirement.
Other attributes of active forms:
- One should be able to default through the form and expect the report to provide information such as “Within normal limits” or “Radiographs normal” or “No existing prosthetics.” This enables a very fast form completion process.
- There should be form choices when doing a comprehensive examinations that allow for quick or complex deliberations.
Finding a system that has these features will help you maintain a high degree of productivity and professionalism when communicating with your patients and colleagues.
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Dental Symphony offers ePatient: the only HIPAA compliant Online Patient Registration System with the exclusive “Pre-Clinical Analysis” tool.
ePatient was created by Dentists for Dentists and is easily adaptable for any type of practice with free customization.