Western DentalOrthodontic Documentation Calibration

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Corporate Offices

Copyright 2009. Western Dental All rights reserved.

These materials have been prepared by Western Dental and represent the confidential proprietary property of

Western Dental. These materials contain trade secrets which are the confidential proprietary property of

Western Dental. None of these materials, nor any excerpts there from, may be copied, reproduced,

duplicated, delivered, or transmitted to any person at any time, unless the prior written consent expressly

authorizing same is obtained from the president or secretary of Western Dental.

 

This training will assist Western Dental providers in mastering the Western Dental orthodontic documentation policies and procedures. Thorough

documentation is necessary to ensure that we provide for the best interests of our orthodontic patients.

Each office will be monitored for compliance with these policies and procedures.

James F. Loos, D.D.S., M.S.Orthodontic Consultant

Louis J. Amendola, D.D.S.Chief Dental Director

Gary L. Dougan, DDS, MPHDental Director

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The following are Western Dental Treatment FormsPlease view the notations on each slide.

All of the documentation demonstrated in this training is required for every patient.

Chart Jacket

EstimatedCompletion date

On the outside of the chart jacket, ensure that staff affix thestart month/year and the estimated completion month/year

so that progress towards completion can be easily monitored.

Start Date

To be used on pages in chart, photos and X-rays

Some of the stickers will have the word “Left” in the lower right

corner. Those stickers are to be placed on panorex x-rays and

FMXs to provide right-left orientation for the x-rays (in

addition to identifying the patient). The “Left” designation must be oriented on or towards the left

side of the patient in the X-rays.

Stickers

LEFT

LEFT

PatientInformationForm

Staff ensures that this is filled

out.

Health History Form

Ensure that the patient is healthy enough for orthodontics as well as any necessary extractions or

oral surgery procedures that may be required to complete orthodontic treatment.

Review this form prior to examination of the patient.

Make sure all lines have a box checked.

Note any conditions requiring premedication or other pre-treatment actions.

Mark any positive answers with your

initials and comments, as indicated.

Your initials verify that you noted the medical condition.

Your comments verify that you asked appropriate questions and investigated the condition to gain an understanding of the condition and its relevance to the planned treatment.

Health History Form

Add any further clarification to “yes”

responses or a summary statement in this area

Health History Form

Patient/Guardian’ssignature/date

Provider’ssignature/date

Update (annually or sooner, when indicated): must include date, any changes?, Dr signature, Dr number, and patient signature.

Medical Alert Stickers

Medical alert stickers must be placed in the record to alert the provider that there are medical conditions that could be of consequence to the planned treatment. Such conditions include need-to-premedicate, allergy (penicillin, latex, metals, etc.), asthma, diabetes, HIV, hepatitis, heart disease, kidney disease, etc.

When indicated, medical alert stickers must be placed on the first page of the progress notes and on each subsequent page.

Medical alert stickers may not be placed on the outside of the chart jacket unless the alert is life threatening (e.g. latex allergy, penicillin allergy).

Initial Exam Form

All items must be completed(numbers 1 to 24)

Phases I or II and full or partial appliance

List extraction or non-extraction or

“probably ---”

List auxiliaries

List # of months of active treatment

Diagnosis,Treatment Plan,

and Perio Screeningform

Form 302b

Under no circumstances may even a single bracket be bonded before this form

is completed by the orthodontist and signed/dated by the patient/guardian !!

Exam SectionFill in Angle Class, OB, OJ, X-bites and any important diagnostic info.

Perio Exam SectionDocument Perio Type and check the applicable perio conditions (calculus, hygiene, etc.) for all patients, even children. Sign and date.

Treatment Plan SectionInclude extractions or non extraction, appliances, auxiliaries, goals, treatment steps and retainers. Also include any related general dentistry, oral surgery, or perio that will be required prior to, during or after orthodontic care (e.g. extractions, veneers to close spaces for small upper laterals, implants for missing teeth, etc.). Note when those treatments will be at additional expense to the patient.

Circle “full” or “partial” and “phase” of treatment

Doctor’s Signature, WD Number and Date!

Parent/Guardian’s signature and Date!!

Form 302b

IMPORTANT!!Patient/guardian

signs here

Any alternate treatment that is appropriate and has been offered or explained to the

patient, i.e. extractions, surgery or similar is to be listed here

If applicable: Also, list additional consent

items such as “patient deniedsurgery, or denied extractions”.Any compromises/limitations in

the planned treatment. For example, list compromises for

treatment plans with lower incisor extractions (possible

excess overjet), lateral substitutions (possible improper lateral disclusion and esthetic compromises), forced-eruption of impacted canines (possible

damage to adjacent teeth roots), non-surgical compromises, etc.

Treatmentmodificationsor reviews are

listed here

Form 302b

Future Treatment Form Use the Future Treatment Form to advise the patient/guardian that general dental and oral surgery procedures are not included in the fees for orthodontic treatment and that those

procedures should only be performed with the orthodontist’s authorization.

Note any other treatments likely to

be required here

Patient or guardian signs/dates here

When Phase I treatment is planned, the Phase I

Treatment Consent Form should be completed and

signed/dated by the guardian prior to starting treatment.

Phase I Treatment Consent Form

1. Be sure to have the patient/guardian sign and date the treatment plan as noted in the previous slides. These signatures demonstrate which alternatives were presented and which option the patient/guardian selected.

2. Be sure to have the patient initial, sign and date the Informed Consent Form.

3. The Doctor and a witness must sign to demonstrate that the “consent process” occurred.

Informed Consent

Office, chart number, andpatient name

Informed Consent

Patient’s or Guardian’s

initials Always

Patient’s or Guardian’ssignature Always

Doctor’s signature and WD Doctor Number, Always

Witness signature Always

Informed Consent

Patient’s or Guardian’s

initials, Phase I only

Compromised Treatment Disclosure

The Compromised Treatment Disclosure should be completed and signed whenever a surgical

treatment plan would be the preferred treatment plan but a non-surgical treatment plan is selected by a patient/guardian. This form

evidences that the patient or guardian has been informed that

the treatment outcome will improve the conditions but not reach all

“ideal” treatment goals

Signature of patient/guardian and date

Signature of orthodontistand date

X

X

Check “Prophy” for all patients

Check any other boxes, as appropriate.

General dentist must complete, sign and date

For all adults, check the area for perio evaluation by the

general dentist

X

Cavity Clearance Form

Check “Caries Check” for all patients

Sign and Date !!

Circle appropriate teeth to be extracted

Also, write out the names of the teeth to be extracted. Ensure that the correct teeth

are identified, and highlight any request that is atypical in such a way to avoid any error by the surgeon (such as mismatched

bicuspids).

Extraction Order Form

Date

Oral hygiene Instruction sticker

(Completed by staff on or before the day

of initial bonding)

Records Approved sticker (Check all

applicable boxes and sign/date)

Oral hygiene grade, to be checked each visit

Elastic pattern, size and instructions For the next visit, enter the

time-needed units and appointment interval (1/4

means 1 time-unit in 4 weeks)

Treatment Notes Form

STOP!Check the recordscarefully to ensure

they are ofdiagnostic quality!

Make sure that photos are labeled with the patient’s

name, date taken, office #, chart #, and name of the person who took them.

Wire type and size (RC is reverse curve of speeand COS is curve of spee)

Next visit instructions

Doctor’s initials and ID#

Assistant’s initials

Procedures performed

Document any adverse conversations, cooperationproblems, prescriptions, and all instructions! Always note just the facts. Do not record your “judgments” of previous

treatment or treatment plans. Do not record “opinions” regarding the patient’s conduct in the office. Write just the facts, exactly as they occurred. Tell the story remembering

that the patient or an attorney may someday read it.

Treatment Notes Form

PleaseWrite

Clearly

Activations

When recording progress notes, always list all materials, appliances and wires used, as well as the instructions given.

Commonly-used abbreviations may be entered (see the attached list).

Activations should be documented as ST (single tie), RT (retie), AW (arch wire), Act (activation), PC (power chain), OCS (open coil spring), Adj (adjustment), etc.

If delivering an appliance, repositioning a bracket or otherwise bonding or rebonding a bracket, always document the accompanying activation, if an activation is performed. It can be accomplished simply by documenting the activation as a single tie or power chain, as indicated.

InitialsID#

Ensure that Staff fills this out completelyEncounter Form

_Date__________

Fill in provider identification

times and procedures

You must perform and document a Perio Evaluationevery 6 months!!!

Check the Perio Type

Check applicable conditions

Sign and date

Perio Periodic Evaluation Form

You must perform a ProgressEvaluation every six months

Date

Document the progress and cooperation in the

applicable areas

Sign/Date

Progress Evaluation Form

Progress Review FormThe Progress Review Form should be completed every six months during treatment. A copy can be given to the patient or guardian and a copy

should be placed in the chart to evidence that cooperation issues

were identified and addressed.

Check a progress box

Check all applicable boxes for each condition that is interfering

with orthodontic treatment

Note any additional comments including any agreements made regarding cooperation (e.g., “if

oral hygiene does not improve by next visit, treatment will be

discontinued and debanded”)

Note whether there will be additional charges for treatment that extends beyond the planned

finish date

Staff fills this in

Financial Ledger Form

Make sure that a guardian or the patient (if 18 or

older) signs and dates this form prior

to de-bonding

Debond or “Congratulations” Form

Retainers Form

The Retainers Form has two copies, one for the patient and one

for the chart. Ensure that the patient/guardian signs and dates the Retainers Form to evidence

that instructions were given.

To be used whenever orthodontic treatment is

discontinued prior to completion (reaching the

goals of treatment)

Patient/Guardian signs and dates

Provider completes,signs and dates

Request for Discontinuation Form

Document when retainers are refused, and obtain an

additional Patient/Guardian signature to evidence that retainers were offered and

were refused

TRANSFERRING PATIENTS

When a Patient is transferring FROM your office to another office

Be sure to promptly send copies of all pre-treatment and progress records including the exam form, diagnosis/treatment plan form, progress reports, X-rays, tracings, photos and treatment notes

Fill out an AAO transfer form and send a copy to the next office

TRANSFERRING PATIENTS

When a Patient is transferring TO your office from another office

Be sure to promptly obtain copies of all pre-treatment and progress records including the exam form, diagnosis/treatment plan form, progress reports, X-rays, tracings, photos and treatment notes

Check the AAO transfer form Obtain progress records (minimum of a panorex and photos)

if the patient has been in treatment for more than 6 months Upgrade any deficiencies in the pre-treatment records Document a treatment plan review and formulate a

continuation treatment plan on the 302b form

Both sides must be completed for

patients who are transferring out !

AAO Transfer Form

Orthodontist signs

Patient’s signatureto release records

AAO Transfer Form

Invisalign Forms

Invisalign Form

Invisalign Express

Managing Provider (Regularly scheduled in that office and is the doctor-in-charge for that office)

Responsible for patient care Responsible for continuity of care Responsible for treatment plans and changes to treatment plans Responsible to monitor chart documentation and treatment times Responsible to train or re-train staff and part-time provider as needed Responsible to provide comprehensive instructions for “next visit” to ensure

continuity of the treatment plan, decision points are addressed timely, and patient compliance concerns are addressed timely

(e.g., 16x22 SS upper, check OH and elastic co-op)

Responsibilities of Managing ProvidersSubstitute and Part-time Providers

Responsibilities of Managing ProvidersSubstitute and Part-time Providers

Part-time Provider (2nd doctor in an office, returns on a regular basis). Responsible to formulate and document treatment plans for new patients.

Borderline cases should be reviewed with the Managing Provider Responsible to monitor treatment plans for continuity with managing provider Responsible to consult with the managing provider before making major

treatment plan changes Responsible to facilitate progress toward treatment completion at every

appointment Responsible to provide comprehensive instructions for “next visit” to ensure

continuity of the treatment plan, decision points are addressed timely, and patient compliance concerns are addressed timely(e.g., 16x22 SS upper, check OH and elastic co-op)

Substitute Provider (not permanently scheduled in that office) Responsible to formulate a tentative treatment plan for all new patient

starts Responsible to review the Treatment Plan the treatment notes prior to

treating the patient Responsible to continue the treatment progress (do not just re-tie) Responsible to follow the existing treatment plan Responsible to make notes regarding current status (e.g., overjet is 4.5 mm,

elastic cooperation in question, etc.) Do not criticize past treatment or change the treatment plan without consulting

the managing orthodontist (if the treatment plan should be changed, leave a note attached to the outside of the chart jacket for the managing provider to re-evaluate the case and make the change)

Respect the possibility that there may be more than one way to treat a case and do not make notes disagreeing with the treatment plan or suggesting a new treatment plan in the treatment notes section of the chart. The managing provider is responsible for the treatment and he/she is responsible for modifications to the treatment plan

Responsibilities of Managing ProvidersSubstitute and Part-time Providers