Periodontal Chart Manual Version 4.81

Transcription

1 Periodontal Chart Manual Version 4.81 Contents Introduction... 2 Perio Module Access... 2 Adding a New Perio Chart... 2 Entering Data... 5 Add Perio Dialog Commands... 5 Viewing the Full Mouth... 6 Compare... 7 Statistics... 9 Treatment History EPR Forms Periodontal Screening and Recording (PSR) Scores Attachments Printing Perio Options Perio Chart Manual Modified: 6-May-10 Page 1 of 13

2 Introduction Periodontal (perio) conditions are cumulative or progressive conditions that require charting over an extended period of time. Using the axium Perio Chart Module to record the state of these conditions on a periodic basis allows the provider to monitor and take action if conditions deteriorate or determine the efficacy of treatment as they improve. Perio Module Access The main Perio module (as apposed to the Perio tab in the axium EHR module) is accessed via the Perio Chart icon on the left side of the desktop, from the Perio Chart icon in the EHR Perio Tab, or from the Actions menu Clinical - Perio Chart menu item. A patient must be selected before opening the perio chart. The main Perio window displays the most recent copy of the perio chart for the patient selected. The display defaults to Maxillary but can be switched to Mandibular by clicking on the up or down arrows. Adding a New Perio Chart Perio Chart Manual Modified: 6-May-10 Page 2 of 13

3 Click on the Add New Form icon at the top of the Perio Chart dialog to open the Add Perio dialog. If a chart had previously been entered and then saved as incomplete the following message will display: To enter a completely new chart select No, to resume an old chart click Yes. If you select Yes to resume an old chart the Select Perio Date dialog will be displayed. Highlight a perio chart in the list and select one of the following options: New To open the Add Perio window without resuming any of the items in the list. Resume To allow users to select an incomplete chart and resume it. This is only enabled if the selected chart is incomplete. This will display the Perio Add window with data filled in from the chart selected. Edit/Review To allow users to select an incomplete chart, review it and possibly make corrections. When selected, displays the Perio Add window for the selected date with the title Edit Perio, the Chart Date enabled and the data filled in like when in Resume mode. Close Off This closes off an incomplete chart so that they can no longer be edited. Perio Chart Manual Modified: 6-May-10 Page 3 of 13

4 Re-Open Undoes the closing off of a chart and allows it to be edited. Both Close Off and Re-Open will add another line in the list with today s date in the Audit Date column. Note: The difference between Edit and Resume is that Edit keeps the perio date as of the date it was first entered. Resume updates the perio date to today. The periodontal chart is divided into 4 views; each view represents a particular quadrant of the mouth. To change the quadrant, use the arrow keys on the upper right of the window. New or Resume opens the Add Perio window defaulting to the Maxillary Right quadrant view. Select the Exam Type from the dropdown list. Exam type is a field that allows the user to describe the significance of the Perio examination date (e.g.: Initial examination, post scaling, pre-surgery, post surgery, etc). This will have more meaning than merely a date. The Exam Type will display: In the title bar on the Perio Manager window. In the Perio Full Mouth View window. In the Select Perio Date accessed via the view form history icon on the Perio Manager as a column titled Exam Type. In the Perio Comparisons dialog accessed via the compare form icon on the Perio Manager in the text of selection combo boxes. In the Info Manager selection list for custom reports. Perio Chart Manual Modified: 6-May-10 Page 4 of 13

5 Select the Perio Charting Date using the drop down calendar control if the values were charted on a date prior to current date. Entering Data With the mouse or light pen select the block corresponding to the periodontal condition, and tooth that you wish to begin charting at. Enter the value of the current condition by clicking on the keypad located to the right of the Perio chart with the mouse or light pen. Or, alternatively type the entry using the keyboard. Each possible value that can be charted for the current condition line is displayed on the lower right of the screen with the Key board entry to chart it. These values will appear in the currently selected tooth section in the Perio chart. Continue entering values for the next selected periodontal location. The program will advance to the next periodontal location as predetermined in Settings. This is continued until all data has been entered. Upon completion, select OK. If your Perio window has been set up to allow this (an administrative setting in the database) the system will automatically calculate the attachment line based on entries made in the Free Gingival Margin and Pocket Depth fields. Alternatively the attachment must be manually calculated and entered. If your Perio window has been set up to allow this (an administrative setting in the database) the system will automatically jump to the bleeding line when you press the key that corresponds to bleeding. Once the bleeding point is recorded, the system will jump back to the condition that you previously charting and allow you to continue without having to select the previous condition. Add Perio Dialog Commands Save To save your work as you go along. Clear All To clear all entries since you last saved. Incomplete To save and close a chart that you wish to resume at a later date. Complete To save a completed chart. Cancel To close the window without saving any changes. Clear Perio Chart Manual Modified: 6-May-10 Page 5 of 13

6 Clears the current cell (but does not auto advance so that the user may re-enter the proper value). Clr Tooth To clear all 3 values for the tooth. For Yes/No conditions, resets them to their "No" value. Up To move up to the next Perio Condition line. Down To move down to the next Perio Condition line. Previous To move to the previous valid site for this condition. Next To move to the next valid site for this condition. Notes/Conditions To enter a condition or note about the currently selected tooth. First, highlight the tooth. Viewing the Full Mouth To view the full mouth, click on the Full View icon on the main Perio window. The following window will open: Select either Text Values or Graphic Values, depending on whether you wish to see the 3D images of the teeth or just the charted condition values. Perio Chart Manual Modified: 6-May-10 Page 6 of 13

7 In graphic mode, to view the chart details, place checkmarks in the box beside the condition in the conditions to display area. The window will refresh and draw the checked conditions on the 3d images of the teeth. Compare To view a Periodontic comparison, click on the Compare Form icon. The following window will open. Perio Chart Manual Modified: 6-May-10 Page 7 of 13

8 Select the condition you wish to compare from the condition drop down. Select the first date you would like to see, and the color you would like it to be charted with. Select the second and subsequent dates with corresponding colors and click accept. The following window will open. For each of the dates selected you will see a line of text displaying the value as it was on that date. The last row shows the amount of change between the dates, and the chart uses bar graphs to display the amount of change. Perio Chart Manual Modified: 6-May-10 Page 8 of 13

9 Statistics To view a perio statistics report click on the View Statistics icon. The following window will open. The Perio statistics report is a crystal report that can be customized by the University. Perio Chart Manual Modified: 6-May-10 Page 9 of 13

10 Treatment History To view the patient s treatment history, click on the Treatment History window will open: icon. The following Here the user can toggle between predefined views of the information. To add new treatment or case notes, open the toolbar by hovering with your mouse over the arrow key to the right, and click on the toolbar option needed. EPR Forms To view the perio EPR record, click on the EPR Forms open. icon. The following window will Perio Chart Manual Modified: 6-May-10 Page 10 of 13

11 The Perio Type and Perio Prognosis can be entered here. The system can calculate some Perio Statistics based on entries made in the Perio Examination and will display them in the middle of the upper section of the window. Periodontal Screening and Recording (PSR) Scores Periodontal Screening and Recording (PSR) is a diagnostic screening tool for the early detection of periodontal disease. To the right of the Perio statistics display in the Perio EPR Forms dialog are the PSR scores for the patient. PSR score values can be calculated by the system or can be manually entered by the provider. If auto-calculated the system will gray out the six PSR score edit boxes. If the user is to enter the Perio Chart Manual Modified: 6-May-10 Page 11 of 13

12 values manually the boxes will be enabled (the check boxes are always enabled - see below for their use). Each box represents an intraoral sextant. Intraoral sextants are designated S1-S6 beginning in the maxillary upper right sextant (S1), proceeding in a clockwise manner, and finishing in the mandibular lower right sextant (S6). PSR codes are based on the following system: Code 0 Pockets <3.5 mm with no calculus or bleeding. Colored area of probe remains completely visible in the deepest crevice in the sextant. No calculus or defective margins are detected. Gingival tissues are healthy with no bleeding after gentle probing. Code 1 Pockets <3.5 mm with bleeding. Colored area of probe remains completely visible in the deepest probing depth in the sextant. No calculus or margins are detected. There is bleeding after gentle probing. Code 2 Pockets <3.5 mm with calculus or overhang. Colored area of probe remains completely visible in the deepest probing depth in the sextant. Supra- or subgingival calculus and/or defective margins are detected. Code 3 Pockets >= 3.5 mm. Colored area of probe remains partly visible in the deepest probing depth in the sextant. Code 4 Pockets >=5.5 mm. Colored area of probe completely disappears, indicating probing depth of greater than 5.5 mm. Code * Denotes clinical abnormalities including but not limited to furcation invasion, mobility, mucogingival problems, or recession extending to the colored area of the probe (3.5 mm or greater). The checkbox is used to indicate a clinical abnormality in that sextant. Code X Denotes an edentulous (missing) sextant PSR scores are calculated on the worst score within a sextant. If pockets are charted and there are pockets of 3.2 mm on one site and 5.1 mm on another tooth site in the same sextant, the calculation will be based on the 5.0 mm pocket. PSR scores are based on the most recent exam performed with an I (in-process), C (complete), or closed status. Perio Chart Manual Modified: 6-May-10 Page 12 of 13

13 Attachments To view the Patient Attachments window (review consents / images / letters etc ) click on the Patient Attachments icon. Printing To Print the perio chart, click on the Print icon. Perio Options Selecting the Perio Options icon displays the Perio Options dialog. Graphing conditions on the teeth themselves can be turned off and on and can the display of condition symbols. The view can be set to user selectable, text only, or graphical only. Perio Chart Manual Modified: 6-May-10 Page 13 of 13