A patient's treatment is entered in the Chart module. You can chart planned treatment, treatment that will be referred out, or existing treatment (done at your office or another location). Entered treatment will show on the Graphical Tooth Chart.
Also available: Webinar - Clinical Charting 1: Entering Treatment
- In the Chart module, click the Enter Treatment tab.
- Select one or more teeth in the tooth chart. Click and drag to quickly highlight multiple teeth.
- Verify the Entry Status. The default is TreatPlan.
- Verify the entry date.
- Select the diagnosis, prognosis, or assign priority (optional).
- Select the procedure(s). There are a few options:
- Click on a Quick Button. These buttons are associated with a single code and designed to quickly chart fillings and sealants.
- Click a Procedure Button. These buttons are associated with multiple codes or Auto Codes and organized by category.
- Click Procedure List to select a code from the Procedure Code list.
- Manually type the code then click OK. If a D code, entry of the D is optional.
If the procedure requires a tooth surface, you can click surface buttons before clicking a button or entering the code, or you will be prompted to enter surfaces after.
The procedure will list in the Progress Notes and show on the tooth chart (if applicable). If information is missing, the Edit Procedure window will open so you can fill it in. Double click a procedure to edit it.
Multiple instances of same procedure: Sometimes you need to add the same procedure multiple times, such as when administering many units of anesthesia. In these cases, add the procedure once, then change the Unit Quantity on the Procedure - Medical tab to account for the additional units. For example, to add 45 minutes of D9221 (deep sedation/general anesthesia - each additional 15 minutes), add the procedure once, then enter 3 as the Unit Quantity.
Entering a Planned Appointment (the next appointment)
Charting Missing Teeth
Charting Tooth Movement
Primary / Permanent Teeth
Drawing on the Tooth Chart
Customizing Chart Views
When procedures involve multiple appointments
Change Code Recommendations
If using Auto Codes, you may receive a prompt to change a procedure code if Open Dental has recognized a mismatch. For example, if you select three surfaces for a two surface procedure code, Open Dental will prompt you to change to the recommended three surface procedure code.
To set whether or not staff is required to accept auto code suggestions, see Chart Module Preferences,
'Require use of suggested auto codes'.
Description of Enter Treatment Options
Tooth Surface Buttons (B/F, V, M, O/I, D, L): Click on a button to populate the box above. To remove an entry, click the button again. The box itself cannot be edited. Most of the tooth surfaces are standard and self explanatory. The "V" surface is the exception. Open Dental uses " V" to indicate a class 5 location along the gingival margin of the B or F. The V surface will draw differently on the tooth chart. There is no corresponding lingual class 5 indicator. Since V is not one of the surfaces allowed when submitting to insurance, it will convert to B or F on all claims. Also, you should not count a V as another surface in addition to B or F because no line angles were crossed. For example, you might have a 2 surface DBV, which would be automatically converted to a DB on outgoing claims. V is also not counted as a surface for Auto Codes. Surfaces are handled slightly differently in Canada.
Entry Status: Determines the procedure status. Status colors are set in Definitions, Chart Graphic Colors.
- TreatPlan (default): For treatment that is recommended, but not yet complete. Procedure(s) will have an entry date and a fee. If added to the active treatment plan, the status will be TP. If added to inactive plans only, the status will be TPi. If no treatment plan is selected, the procedures are added to the active plan. See Treatment Planning from the Chart Module.
- Complete: For work that you have already completed. Procedure(s) will have a fee.
- ExistCurProv: For treatment that was done in your practice prior to using Open Dental. Procedure(s) will have no fee.
- ExistOther: For treatment that was done by another provider, either
before the patient came to your practice, or because they were referred out for treatment. Procedure(s) will have no date and no fee.
- Referred: For treatment the patient needs, but that will be done at another office. Once the work has been completed, change the procedure status to EO. Procedure(s) is usually has the date of the referral, but no fee.
- Condition: For charting
conditions or watches. Can be used in conjunction with dummy Procedure Codes for any condition you want to see on the tooth chart. The mouth area and paint type of each dummy code must be carefully set.
Date/Today: The procedure's entry date. Check Today to insert today's date. To enter multiple procedures with a previous date, uncheck the today box, then enter the date first, before entering treatment.
Diagnosis (optional): One diagnosis can be set per procedure. Diagnoses do not show on the graphical tooth chart. Customize options in Definitions, Diagnosis. To see diagnoses separately from the proposed treatment, use the Condition (Cn) entry status.
Prognosis (optional): Not used by most offices. Customize options in Definitions, Prognosis.
Priority (optional): Used to prioritize treatment planned procedures. Customize options in Definitions, Treat' Plan Priorities.
Treatment Plans: Check this box to show treatment plan information in place of the Progress Notes. This check box only shows when 'Is TP View' is also selected for the Chart View on the Show tab. See Treatment Planning in the Chart Module.
Problem: A patient had a hygiene appointment today. Now when treatment planning, procedures are showing in the progress notes as being assigned to the hygienist instead of the provider.
Solution: Check the appointment (double click) and make sure the dentist is set as the Provider (not the hygienist). The hygienist should be set as the hygienist. You may need to reenter treatment to update the provider.
When treatment is entered, and there is already a scheduled appointment for the day, the provider on the scheduled appointment is always initially assigned.