for dental students
Writing Progress Notes for an Exam and Cleaning
PHTEN
This is the format that is being used by McGill University dentistry students for writing progress notes when they see patients.
What Does It Mean?
PRESENTATION: In what context is the patient presenting themselves? What is the reason for their visit?
HEALTH: Medical and dental health status of the patient.
TREATMENT: Treatments rendered. Results of objective data collection, both clinical and radiographic.
EVALUATION: Subjective assessment of findings. Diagnosis. Prognosis. Patient behaviour. Discussion with patient, including consent. Treatment plan.
NEXT: What is to be done next visit? If there is a priority, then specify the treatment.
An Example
P: 25 M presents to summer clinic for recall exam with CC = "I'm here for a cleaning."
H: MedHx- Unremarkable. Meds- Denies. NKDA. Denies tobacco, EtOH and illicit drug use. DentHx- Brushes 2x/d. flosses 1x/d. LDV 1 yr ago in summer clinic.
T: H&N exam performed. E/O: NSF. I/O: ST- NSF. PSR 222/222.
Dental- See odontogram. Caries 13M in proximity to pulp space. Retained root #16.
4 BW taken- incipient caries noted on 26M, 36M, 45D.
Scaling of maxillary and mandibular arches with US scaler and hand instruments.
Prophied. Flosses. OHI. Topical fluoride 5%.
E: Discussed treatment alternatives, cost, benefits, risks for tooth #36: 1) RCT re-treatment, post, core, PFM crown +/- CCL on buccal. 2) Exo and implant. Pt decides on exo with implant tooth 36 after recent implant surgery #35 healed. Will recement fallen crown as short-term solution.
Monitor: 17O, 16M, 14O, 22L, 26O, 36M.
Tx required: Exo - 15, 16. Operative - 26MOL (A).
N: Pt to return for operative.