Peer Dental Chart Monitoring Tool

Date of Birth Name (Last, First)Date of BirthName (Last, First)

1.______6.______

2.______7.______

3.______8.______

4.______9.______

5.______10.______

Indicator: Medical History / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Comprehensive health history present with yes/no responses.
2. Name, telephone no. address or physician or none.
3. Health hx. Completed and signed and dated by pt./guardian.
4. Health hx. signed and dated by dentist.
5. The medical hx. Is updated annually.
6. Significant medical conditions are prominently displayed without breach of confidentially.
7. Baseline blood pressure is recorded with hx..of high blood pressure.
8. Follow-up for medical complications before dental tx.
9. Health precautions for dental tx. taken.
10. If a chief complaint was reported, was it addressed?
Score
Indicator: Emergency Care / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Emergency care was approp. with timely f/u if needed.
2. Attempt to transition to reg. care.
Score
Indicator: Radiographs / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Current films mounted, dated and identified.
2. Quality of radiographs permits a comprehensive dx.
3. Quality of radiographs permits a comprehensive dx.
4. Recall films taken at appropriate time intervals.
5. Adequate recall radiographs.
Score
Indicator: Diagnostic Information / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Existing restorations, appliances and missing teeth are charted.
2. Periodontal screening performed (pocket markings for screening or Type 1,11, 111, 1V).
3. Soft tissue oral cancer exam.@ initial visits.
4. Soft tissue/oral cancer examination performed at recall visits.
5. Occlusion noted (Type 1,11,111) or orthodontic referral documented.
6. TMJ screening performed (WNL) or inc. in health hx.
7. All pathology visible on radiographs is diagnosed.
Score
Indicator: Treatment Plan / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Tx. plan resent, updated when needed, and sx. By pt./guardian.
2. Treatment plan consistent with dx.
3. Tx. plan specifies alternatives, incl. covered & non-cov. options, when appropriate.
4. Sequence of tx. is consistent with recognized standards or documentation of reason for deviation (per progress notes or tx. plan page).
5. Plan includes necessary specialty referrals.
6. Pt. financial responsibility is specified, signed and dated by pt./guardian (may be on the same page as tx.plan)
7. Excessive charges present.
Score
Indicator: Informed Consent / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Consent form is comprehensive or procedure specific is present, dated, signed by pt./guardian and dentist or an informed consent process is documented in the notes.
Score
Indicator : Periodontics / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Full mouth pocket markings documented when indicated by periodontal screening (> type 1)
2. Periodontal dx, is consistent with radiographs & dx. Information.
3. SRP with re-evaluation and/or periodontal referral recommended.
4. Professionally recognized tx. delivery (4Q SRP/visit has an explanation).
5. If available post-op radiographs show effective calculus removal after prophylaxis and/or root planning and scaling; or documentation of pocket reduction within three (3) months; or elimination of bleeding on probing.
Score
Indicator: Preventive Care / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Dental prophylaxis is documented at least annually.
2. When appropriate, fluoride tx. recommended.
3. OHI is recommended.
4. Prophy recall period documented (# of months or actual date).
Score
Indicator: Endodontics / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Initial and final radiographs present.
2. Use of rubber dam is evident in notes or on X-Ray.
3. Canals are well prepared and filled (no silver points or paste fills).
4. Treated teeth are appropriately restored.
Score
Indicator: Restorative/Fixed/Removable / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. If recall radiographs are available, restorations placed by provider appear acceptable.
2. If recall radiographs are avail. Crowns and bridges placed by provider appears acceptable.
3. Teeth dx./tx. by provider have adequate periodontal support.
4. Missing teeth tx. planned for replacement when appropriate.
5. For new denture(s), there is documentation of standard fabrication, delivery and post-delivery appointments.
Score
Indicator: Oral Surgery / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Reasons for extractions are documented.
Score
Indicator: Pedodontics / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Sealants provided when appropriate.
2. Separate maint., and behave. Issues noted.
Score
Indicator: Overall Chart / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. Chat is organized, legible and in ink.
2. Entries are dated and sx.’d by provider.
3. Procedure (s) adequately and described.
4. Anesthetic, vasoconstrictor and dosage noted.
5. Medications prescribed are documented, including :sig.”
6. Necessary post-op inst. for surg. procedures.
Score
Indicator: Continuity of Care / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / Score
1. F/u documented for failed appointments and/or failed recalls.
2. Timely completion of tx. or documentation of reason for incomplete/protracted tx. present.
3. Chart indicates tx. for next. appointment (“NV”).
4. Specialty referral f/u documented or tracking system is present. Ten-day time frame for sharing information between GP and specialist.
Score-
Total
score

1

Key-

Y=Yes

N= No

A=Not applicable