Have a Question?
Limited Exam
- Basic kit
- Air/water syringe
- Bib/clip
- Gloves for Dr.
- Safety glasses
- Seat patient and ask
- I understand you are having a problem with ________. Tell me about it. (Be empathetic)
- Are you having any sensitivity to: sweets, hot/cold, pressure?
- Does it wake you up at night?
- Have they been prescribed antibiotics/pain medications for their current problem?
- Any follow up questions you feel are needed.
- Take a PA x-ray and/or intraoral picture,
- Take an Intraoral picture of anything that will not show up radiographically on a PA x-ray.
- Examples: missing porcelain of a crown, any tissues anomalies/sores, and ect.
- Notify the Doctor that the patient is seated and of the patients wants, needs, desires and any other pertinent information.
- Have Front desk create (your create it yourself) & print a treatment plan for patient. Take treatment plan back to patient.
- Chart appointment in patient’s chart. Make any changes or adjustments to patient appt. in the computer and Add your name in the assistant field if not already there, then complete the appt. in the computer.
- Take pt.’s chart up front so they can submit pt.’s insurance, be prepared to schedule pt.’s next appt. & treatment plan any changes to pt.’s current treatment plan.
- Inform the patient of what their next appointment will be. Ask if the patient has any questions, & escort the patient to the front desk so they can check out.
Subjective
Chief complaint:
On a scale of 1-10:
Location of pain:
Sharp/dull/throbbing:
Pain keeps patient up at night:
Pain has lasted:
Sensitivity to hot, cold, sweets:
Pain to biting/chewing:
Facial swelling:
Medications for relief:
Objective
Clinical Exam
Extraoral (Asymmetry, swelling, erythema, paresthesia, TMJ):
Intraoral (Swelling, exudate, erythema, hemorrhage, mobility, occlusion, pain, biotype, hard tissues):
Radiology (PA, Pano, CT):
Assessment
Plan