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Download Case Study/ Treatment Planning - PreClinic-2015
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Case Study Presentation Team Number Team Member Names Date Template adapted from “Case Study/Treatment Planning” by Ann Wetmore and Mosby’s Dental Hygiene Concepts, Cases, and Competencies (2nd ed) Case Development Worksheet Case Selection Criteria • Selection Criteria: State the criteria by which you selected the case for presentation. Assessment Patient Information • Profile: Summary of the basic information about the patient (e.g. age, psychosocial history, cultural influences, social factors, barriers to care, etc.) Chief Complaint • Provide documentation of the patient’s chief complaint and how it was addressed Medical History • Based on client’s medical history, provide summary of patient’s systemic health and ASA Classification • Describe the client’s vital signs • Include a copy of the client’s health history Medication History • Include a summary of the client’s medications and their effect on dental treatment • Provide evidence of client’s medications (bright pink form) Dental History • Include client’s last DHT visit • Describe history of previous dental surgeries, procedures, ortho, etc (from green EO/IO form) EO/IO Exam Findings • Provide overview and documentation of EO/IO findings • Use proper lesion description for all deviations from normal • Include intra-oral photos for significant findings • Include EO/IO form Occlusion • Include description of occlusion classification • If possible, provide pictures of occlusion Plaque Control Record • Provide documentation of the client’s initial plaque score using Eaglesoft • Was there light, moderate, or heavy plaque? Where was it primarily located (gingival margin, interproximal, posteriors, etc)? • What were client’s current homecare practices at the first visit? Calculus Detection • Include a copy of the client’s calculus detection. • Does the client have light, moderate, or heavy calculus? • Is there subgingival or supragingival calculus? • If possible, include pictures of supragingival calculus. Radiographs • Include radiographs for client • Discuss any key anomalies or findings on the radiographs. Dental Chart • Provide copy of dental chart from Eaglesoft • Summarize dental findings and conditions • May include intraoral photos Dental Hygiene Caries Exam • Summarize dental hygiene caries exam findings (suspicious areas) • Include a summary of diagnodent findings Perio Chart • Provide summary of periodontal findings • Include copy of Eaglesoft periochart Dietary Assessment • Gather the dietary assessment (complete 24-Hour Food Record/Nutrition Assessment Form) for your client • Specify any current or potential nutritional deficiencies • Evaluate the potential impact the various issues may have on oral health Oral Risk Assessment • Attach copy of the Oral Risk Assessment form (back of consent form) • Provide summary of risks and recommendations Diagnosis Gingival Description and Periodontal Diagnosis • Provide summary of gingival description ie. pink, firm, puffy, edematous, etc. • Include the periodontal diagnosis Caries Diagnosis • Discuss dental exam findings • Include dental exam form (blue form) • Describe any referrals recommended Planning Care Plan • Include copy of care plan • Summarize findings and anticipated outcomes Hygiene Treatment Plan: Appointment Sequence • Formulate a dental hygiene treatment plan • Sequence appointments according to priorities based on patient needs • Include the back of the care plan Consent for Treatment • Include and summarize consent for treatment form Restorative Treatment Plan • Include and summarize restorative treatment plan from Eaglesoft Implementation Patient Education • Provide details about your preventive education • Include specific homecare aids recommended and describe techniques demonstrated • Describe follow up plans for this patient Preventive Product Recommendations • Include any products recommended for the client and why (e.g. toothpastes, rinses, mints, gums, etc) Services Completed • Describe treatment provided for the client during each phase of treatment including: – Debridement details (amount of plaque/calculus found during instrumentation, difficult areas) – Polish (selective or coronal, type of prophy paste used and why) – Fluoride (type and percentage and why) Evaluation Outcomes Evaluation • Discuss the outcomes of treatment and education provided • Review whether completed care addressed the client’s goals, risks, patient concerns • Include actual outcomes column of care plan Oral Self-Care Evaluation • Provide summary of patient’s understanding and effectiveness of oral hygiene • Include final PASS score and discuss changes made in plaque score throughout appointment sequence Future Care Recommendations • List any future care recommendations based on evaluation data • Provide documentation of any further referrals needed • Supportive care interval: recommended interval for recare Evaluation and Assessment • Utilizing self-assessment skills, list any modifications that could have enhanced treatment outcomes Documentation Operations Performed • Provide copy of autonotes from Eaglesoft
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