Patientname______Hospital Number______

Student Name______

Using this Treatment Planning Form:

This form is intended to help you plan more complex cases and to enable clinical staff to see that a plan has actually been made and to see where the treatment has reached. It is the minimum level that is needed for a complex plan if control is not to be lost.

  1. Find out what the patient wants out of the treatment. This may be simply “I do not want anything removable” or “I want to be able to eat in comfort”. You will have to explain to the patient some options although in many cases these cannot be finally decided on until further investigations have been carried out.
  1. Carry out all your investigations special tests etc. and write these up in the notes as usual. Then summarise these in a concise form using the large charting form and Diagnosis sections (overleaf) on this form. You can enter the perio on the chart either as BPE or 6pt pocket charting as appropriate. Perio treatment is monitored on a conventional perio form. The Status line on the charting means:

XT definite xtn, hopeless tooth.

? questionable as needs investigation and re-evaluation.

R restore as charted/listed PR – prosthetic replacement as charted/listed.

  1. Decide whether you need a stabilisation phase and which teeth need further investigations. This does not mean for instance vitality tests but things like caries removal to assess restorability and the method of restoration. It may include the outcome of periodontal treatment. This does not preclude further treatment taking place during this period e.g. plastic fillings during the perio healing phase. Discuss these with your supervising clinician and enter the appointment plan for the investigation/stabilisation phase on the treatment schedule (back page). Get it signed off by the clinician when this is done.
  1. At the end of the investigation/stabilisation phase review and enter up any changes from the initial provisional plan.
  1. Discuss the viable options and enter the chosen one.
  1. Enter the treatment items needed.
  1. Plan the final appointment plan and enter it in the schedule. Remember this is a detailed plan and must include all stages of e.g. RCT/lab work. Get the final plan signed off.
  1. At the conclusion, review the treatment and enter any things learned in your reflective learning book. Plan a maintenance regime. List any fallback/further treatment options. Arrange ongoing treatment or handover to another student. This is part of your professional responsibility.

Treatment Planning Form
Name: / Number:
SIGNIFICANT MED HISTORY / YES NO (Delete as needed)
Patient wishes for outcome of treatment:
Diagnosis (includes findings from radiographic, occlusal, vitality tests etc);
Soft tissues
Periodontium
Perio risk factors
Coronal tooth tissues
Endodontic
Occlusion
Prosthetic needs
Aesthetic needs
Treatment objectives:
Investigation/stabilisation needed for;
Investigation/stabilisation schedule approved by / date:
Results of investigation phase;
Treatment Options:
Option selected:
Items of treatment needed for option selected;
Stage I treatment schedule approved by / on
Final treatment schedule approved by / on
(If all treatment can be accommodated in one schedule enter as final schedule)
Initial maintenanceschedule hyg @ / for / dent in / then
review maint. plan. Hyg to monitor using these indices;
Prognosis and possible long term treatment needs considered at this stage;

Name______PIN______

Status.
Furc/Rec/Mob.
Perio.
Vit.
Cavs. / /
Rests. / / / / / / / / / / / / / / /
8 / 7 / 6 / 5 / 4 / 3 / 2 / 1 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8
Rests. / / / / / / / / / / / / / / / /
Cavs.
Vit.
Perio.
Furc/Rec/Mob.
Status

TREATMENT SCHEDULE

Hyg/Dent. / Date / Length / Treatment to be done / Interval to next appt / Lab to do

MED HIST AFFECTS TREATMENTYES/NO(Delete as appropriate)