Treatment history is the documentation of what services were performed for the patient. The document cannot be altered after the information is entered and saved for a specific treatment visit. Additional visits can be used to add additional information, but of course with a different time and/or date.
Setup of the Practice and Doctor Information
Before using the treatment history, it is important that you input the information about your practice. On the menu bar, click Program | Options, and then click the tab labeled “Practice Information”. Complete the practice information that will be used when appliances are ordered and when patient files are printed.
For the purposes of treatment history, all the doctors in the practice should be entered into the field at the bottom of the practice information tab. A treating doctor will be assigned to each patient.
Starting Treatment with a New Patient
When entering the initial patient data, be sure to also assign the “current doctor”. The doctor name(s) should be already listed after the setup of the practice information described above.
Before starting the treatment history, be certain that the months of expected treatment have been entered into the “Patient Expectations” tab. The program also requires that a treatment option be selected to save the data for a patient visit.
After the above data has been entered, then click on the treatment history tab, and then click the “Begin Treatment” button. Select the type of appointment, and you are ready to enter the procedures performed on that day.
Starting Treatment with an Existing Patient
When you first start using the system, there will be existing patients who need to be entered. When you first enter the record for this “new patient” to the system, assign a current doctor, months of treatment, and treatment plan.
Click on the Treatment History tab and then the “Begin Treatment” button. Select the type of appointment and you are ready to enter the procedures for that day.
Type of Appointment
Drop down the box and select the type of appointment for this day.
Month of Treatment
The current treatment month is the number of “monthly visits”. The month since start indicates the chronological month since the treatment start for the first number, and the number of expected treatment months from the patient expectations tab. Using this feature, a patient who does not come for treatment every month will show less treatment months than months since start. The treatment month may be 10 months, and the chronological month timer may be 24 months in an expected 24 months treatment. When the patient is asking why they are not getting their brackets off today, you can show them that they effectively are at 10 months of treatment, not 24.
The Treatment Diagram
In cases where the IP Appliance has been designed in the software, the appliance will automatically transfer when the begin treatment button is selected. For patients who have not had IP Appliance design in the software, it is helpful to indicate the missing or extracted teeth, teeth with bands, and teeth with brackets using the “tools” located above the diagram. Click on one of the tools, move it to the tooth to receive the band or bracket, and click again. Repeat on all the teeth to receive a bracket or band. To change the tool, move the cursor to the arrow and click.
After entering the brackets, bands, and extracted teeth for the first time, it will be necessary to highlight all the notations in “services rendered this month” and then press the “delete” key on your computer keyboard to erase all these notations.
Selecting Treatment without Typing
For those that do not wish to type, and for those that want to receive the notes in reminders and suggested treatment (next month), you may “right click” the mouse on any of the teeth in the diagram.
General leads to general procedures that you may commonly perform. Highlighting general-retie with a left click will result in this writing to appear in the services rendered this month box.
Tooth specific procedures are common procedures that may be performed on the selected tooth. For this to work, you must click on the correct tooth.
Treatment Decision/View Treatment Plan
Treatment decision is the treatment decision that is “marked” in the treatment options tab. For mixed dentition cases, click on treatment option #150, which is also a link to the mixed dentition cookbook. The view button allows you to view the treatment plan that has been selected and edited in the treatment options tab.
This is the first information you wish to see when you first sit at the chair with an existing patient. What did I do last month and what did I plan to do this month. Review of past treatments can be easily referenced by clicking on the date at the bottom of this window.
Services Rendered this Month
"Services rendered this month" is the documentation of what was done on the patient. This can be simply typed into the system or a right click on the diagram for procedures. Reminders and suggested next visit are only activated when the diagram method is used.
This is the expected treatment that you think you will be doing when you see the patient for the next monthly visit. The program will NOT save until you have written something into this box. You will be happy you did when you sit down next month with the patient and have a starting point.
This is an ever-building section that will remind you of key elements in the treatment that are commonly forgotten.
Review Previous Treatments
This is a list of the past patient visits. Click on any date and the services rendered will be made visible.
Saving the Patient Data
Click the button under the next month box. You should get an ultimatum that changes must be made now, or never. Next, you will be asked who completed the documentation this month, which is commonly a dental assistant. The name of this person then is retained for future reference, if needed.