Please follow the steps below when seeing patients for a Periodic Oral Evaluation in the pediatric clinic. The Periodic Oral Evaluation and Comprehensive exam on pediatric patients are essentially the same procedure. The biggest differences to be cognizant of are the codes being added into Axium and the patients will not be given a new medical history sheet when checking in.
Remember to tell a resident or attending prior to starting if this is a competency procedure.
1) Patients will check in with the scheduler who will mark them red on the Axium schedule.
2) Review the medical history form thorougly prior to bring the patient back into the clinic. If you have any questions or concerns regarding the patients medical history this is a good time to bring it up to the attending or resident.
3) Bring the patient and their guardian in from the lobby. Review the medical history form with the patients guardian. Remember to review past dental history, ask about oral hygiene, diet, trauma, and habits. Don't forget to record the patients height and weight (Scale is located beside the stickers near the back of the clinic). This information must be entered into Axium under Pediatric Medical History 2013.
4) Briefly examine the patient to determine which radiographs are necessary and take those x-rays before calling over a resident or attending. Please review the AAPD guideline on prescribing radiographs here.
5) Complete the pediatric comprehensive exam form in axium. This form will help guide you through the exam and ensure nothing is missed.
6) Complete a hard tissue exam. Enter existing and planned treatment in axium. You can use a paper form if you are unsure of the findings and enter into axium after faculty check. All findings must be correctly entered and approved by faculty before the patient is dismissed.
7) Disclose and determine plaque score
8) Review OHI at an age appropriate level then complete a dental prophylaxis
9) Have resident or attending examine patient and assist with treatment planning
10) Apply fluoride varnish after treatment planning is complete
11) Provide toothbrush and prizes to patient following fluoride treatment
12) Enter all procedures performed during this visit, treatment plan, and complete an informed consent if treatment is warranted at next visit (ie. other than recare exam). Informed consent should include all future planned treatment. Complete a yellow appointment form with what needs to be done at the next visit.
13) Escort patient to parent/caregiver, and inform parents of findings and treatment plan. Inform them of oral hygiene recommendations and dietary counseling. Please be cognizant of HIPAA and be discrete.
14) Escort patient and parent to schedulers window to schedule next appointment. Give scheduler paper medical history and yellow appointment form. Stay with patient and family until all questions are answered.
15) Enter all procedures performed in Axium and write up a progress notes using one of the approved note templates. These can be accessed by selecting one of the pediatric clinical note codes (Add a general note, click on the ellipsis beside code and select the applicable note). Another copy of the note templates can be found here.
16) Clean dental chair, place used instruments on dirty cart located next to red bin in clinic, and set up chair for next appointment.