Clinical charting is the ability to graphically record dental history in a chart-like format. The chart consists of an illustration of the patient's 32 teeth on which graphics of dental procedures are depicted, as though you were looking directly at the patient. You can also record patient progress notes in the chart.
This topic is divided into the following subtopics.
See Using this Screen
See Charting tab
See Previous Dental Work
See Planned Treatments
See Pretreatment Estimate Claims
See Printing Planned Treatments
See Applying Planned Treatments in Scheduler
See Notes tab
See Images tab
See Treatment Plan(s) tab
The chart is completely integrated with the patient ledger and the scheduler, as well as other parts of the program. DentiMax's charting feature is flexible and customizable so the staff can easily tailor the screen to fit each person's preferences and needs.
The first thing the dentist is going to want to do is view the patient chart. With the appointment selected, click View Patient Chart in the Options bar.
Using this Screen
The top left portion of this screen shows six default tabs containing icons which represent procedures. Choose the tab you need or create one that suits your needs. Click Charting Input Tabs for more instructions on how to use the input tabs.
Before you begin charting, be sure the graph accurately represents the patient's teeth. By default, all teeth are marked as permanent teeth. If the patient is a pre-teen with mixed dentition, right-click each primary tooth in the graphic and choose Primary Tooth. If all teeth are primary, choose Change all to Primary. When changed to primary, some teeth are removed from the graphic, and those remaining change their shape to reflect the type of tooth, permanent or primary. In addition, the tooth designation is changed from a number to a letter, and the letter is in red print. If some of the teeth are permanent and some still primary, this distinction is easy to identify because of the letter/number designation and color.
Next, identify tooth conditions. Conditions are similar to medical diagnosis codes. The major difference is that dental conditions are not included on a claim.
The View Mode (in the Charting tab in the middle section below the tooth graphic) controls what markings are shown in the tooth graphic. C stands for current condition of the teeth. P stands for planned treatments. P with the check mark stands for procedures that have been completed. O with the check mark stands for work performed by another dentist. You can view all or any portion of these four options at a single time.
Before marking the Chart, be sure the Entry Mode setting is correct. If you think you are creating a treatment plan and have the C selected, all markings you make will appear as current conditions, rather than planned procedures.
Also, you may want to choose a color for each category. Otherwise, the colors shown in the graphic are determined by the individual service codes (in the Code Entry screen). The graphic could get very colorful in a hurry. Many offices assign Red for planned treatments and Blue for completed transactions (whether completed in your office or previously). Conditions can be whatever color you choose, such as Olive Green.
For now, be sure you have selected C.
The Entry Mode setting is also very important when using the patient Chart. Select C here as well, so you can enter conditions.
For now, open the Conditions tab in the top left portion of the screen. You can move the cursor over the icons in the tab to see what each represents. Click the Abscess icon and then click tooth #14. Notice the circle shown above the tooth.
If you make a mistake, click the tooth a second time to remove the marking.
Also notice that Abscess has been entered as a condition in the Charting tab list and no charge has been assigned to it. If the wisdom teeth are missing, click the missing tooth icon and then tooth #s 1, 16, 17, and 32. Those teeth are removed from the Conditions display.
Continue filling in conditions.
Each time you add information to the Chart, a note is made in the Charting section at the bottom of the screen. If you add a condition to more than one surface of a tooth, the Charting section reflects the changes -- updating the Account code if necessary, and reflecting the surfaces.
Previous Dental Work
This patient was treated previously by another dentist. To mark that work, click the Treatment Completed by Another Dentist option in both the View Mode and Entry Mode sections. This way you can view the completed treatment items as they are entered.
Now open the Endo/Perio/Surgery tab. Select the Root Canal icon, then click tooth #31. Notice the lines added to the roots of this tooth. A new entry has been added to the list below, this time with a Status of Completed Other and no associated fee is included.
Now, you need to add planned treatments to the chart. Treatment plans are new procedures that the patients need to have performed. Be sure the P is selected in both the View Mode and Entry Mode sections.
Again select the Root Canal icon but this time click tooth #14, the abscessed tooth.
Open the Restorative/Pedo tab. Click on the crown icon and then click tooth #14.
Next click the Prefabricated Post and Core icon and click tooth #14. Notice that three planned procedures have been entered in the list at the bottom of the screen as well as corresponding fees. The fees are pulled from the patient's insurance file.
After entering the planned treatments, you need to order them so they occur in the correct order. To make this easier, deselect all types of entry except Planned in the View Mode section. Now only planned procedures are shown in the list.
Highlight the root canal (Service Code D3330) and the prefabricated post and core (by holding down the CTRL key and clicking each) and then press the number 1 on the keyboard. Next select the crown procedure and assign it 2. The numbers are different colors to help identify the order.
If you create a planned treatment for a patient who already has an appointment scheduled with treatments included, the program asks if those treatments should be added to this plan.
Pretreatment Estimate Claims
If you want to be sure a planned procedure is covered for a patient, highlight the procedures and click Create Pretreatment Claim in the Options bar. A new claim is created. Double-click it in the Claim screen. No billing is number assigned to it. Review and print it as you would a regular claim. Notice when reviewing the claim that the Request for Predetermination/Preauthorization box is checked in box 1.
The format for the treatment plan estimate can be customized in the Reports section of the program.
Printing Planned Treatments
Once created, you can print the planned treatment and have the patient sign it. To view the patient plan, click Treatment Estimate. You are prompted to save the changes. Click Yes.
Complete procedures might be included in the Treatment Plan Estimate screen. You don't want them printed as part of the planned treatment estimate, so hold down the CTRL key and click the procedures you want included then click Print Estimate (Selected).
Applying Planned Treatments in Scheduler
It's now time to schedule an appointment for the patient to return for the root canal and prefabricated core work. Return to the Chart screen by clicking Close Screen, then Save Changes. This returns you to today's scheduler.
Using the calendar in the upper left corner, choose a future date for this appointment.
Double-click a time slot to open the Appointment Entry screen. Using the drop-down arrow, select this patient. Now, in the Add From Treatment Plan link, highlight the first procedure that appears with the blue #1 in the Order column. Double-click the red arrow that points downward to also select the root canal and prefabricated post and core procedure and add them to the appointment.
Click Close Screen. The selected procedures appear on the newly created appointment with their corresponding fees.
The information entered in this Notes tab is just for the doctor's information. It does not appear anywhere else in the program. These notes can be printed by pressing F2.
You can add images to the Images tab.
Right-click in this tab and select
. These images can be sent with claims.
Treatment Plan(s) tab
This tab is useful for someone who is planning cosmetic dentistry, such as a bridge, implant, etc.
Create plans that include a particular type of procedure.