Enter Treatment

Procedures can be entered from the EHR using one of two methods:

  • Treatment Planning module: This is an optional axiUm+ module used primarily by dental students to plan and present multiple treatment options, usually at different price levels. Once the options have been approved by faculty, they are presented to the patient who will choose and accept one of the treatment options.

    • Important: Until approved by the patient, no treatments display on the patient's record. Once approved, the selected treatments will display on the patient's record with a status of planned.

  • Chart Add tab: This is the main method for entering treatment to a patient’s record and is the focus of this section. The Chart Add tab allows you to enter and update planned, in process, and completed procedures, conditions, and materials from the EHR. When necessary, you can also add findings to ensure the patient’s record is complete. These are previously performed procedures and pre-existing conditions and materials.

    • Important: The Chart Add tab does not display as a tab until you click the Create a new Record () icon from either the Tx History or In Progress tabs, or the odontogram.

Notes:

  • You can also add or edit planned/in progress/completed surface-based procedures on sites with implants for missing or extracted teeth.

  • Implants may be pre-existing findings or planned/in progress/completed procedures at your institution.

Important: You can add a planned procedure to a planned/in progress implant but cannot add an in process/completed procedure to a planned/in progress implant.

  1. Select a patient, open the EHR module, and click the Tx History or In Progress tab.
  2. Click the Create a new Record () icon to display the Chart Add tab.

    3. Depending on configuration, the Chart Add tab defaults to one of four sub-tabs:

    Uses selected tooth/surfaces and diagnosis to filter the list of applicable procedure codes.

    1. Select a diagnostic category from the Diagnosis drop-down list to display a list of sub-categories.
    2. Expand the appropriate sub-category and select a diagnosis.
    3. Select the relevant areas of the mouth on the odontogram to filter the procedure list based on: No selection, Tooth, 1-4 surfaces, 5 surfaces, or Root.
    4. Select a procedure to skip to Step 3 or double-click a procedure to move to the Details sub-tab.
    1. Use the displayed Quick List of Diagnostic Categories and sub-categories to identify the appropriate diagnosis. Alternatively, use the Full List or Search tabs to locate the diagnosis.
    2. Double-click the diagnosis to move to the Procedure sub-tab.
    1. Use the displayed Quick List to select the procedure code. Alternatively, use the Full List or Search tabs to locate the code.
    2. Double-click the procedure code to move to the Details sub-tab.

    Note: Depending on information selected in previous tabs, several fields may be auto-populated.

    1. Complete the fields as necessary.
      2. Field Description
      Provider

      This defaults to the logged-in provider.

      If necessary, click the ellipsis to display the Providers List window and select the treatment provider.
      Date

      This defaults to the current date.

      If necessary, change the date to the appropriate treatment date.
      Code

      Enter the procedure code being added to the patient record.

      Tip: You can also click the ellipsis to display the Procedure Codes List window and select the procedure code.
      Unit

      This defaults to the units specified in the procedure code setup and affects the treatment charge if the procedure code is set up with factor units.

      Note: If factor units are configured, the Maintenance > Clinical > Procedure Code window > Options section > Factor Units? checkbox is selected and the text field displays a value.
      Desc. A read-only field that displays the description of the selected procedure code.
      Site

      Enter the tooth site for the procedure.

      Notes:

      • If the procedure code requires multiple sites (e.g., a bridge), the second site field is enabled.
      • To add the procedure on multiple teeth (e.g., multiple extractions) you must select the teeth using the odontogram. The Site field will display ++ to indicate multiple procedure sites.
      Surfaces

      If applicable, enter the surfaces on the tooth that this procedure applies to.

      Tip: You can enter the surfaces in this field or select them on the odontogram.

      Discipline

      This is the discipline associated with this procedure.

      If necessary, select a treatment discipline from the drop-down list.

      Note: The entries are configurable from Maintenance > Clinical > Tx Disciplines.
      Phase / Sequence If used, enter the phase and sequence for this procedure.
      Diagnosis

      The diagnosis associated to the procedure.

      Click New item to begin typing a diagnosis. Intelli-sense will display matching diagnoses.

      Tip: You can also click the ellipsis to display the Select Clinical Diagnosis window and locate the appropriate diagnosis.

      Custom Fields Enter any information for custom fields configured by your institution.
  3. When ready, click the appropriate icon:

    • Add Finding () icon to add this procedure code as a finding (in this case and existing procedure) to indicate previous procedures completed at another institution.

    • Add Planned Tx () icon to add this procedure as a planned procedure to be completed at a later date.

    • Add In Process Tx () icon to add this procedure as an in process treatment. This requires users to be able to enter procedures without first planning them.

    • Add Complete Tx () icon to add this procedure as a completed treatment. This requires users to be able to enter procedures without first planning them.

  4. If adding a surface-based procedure with any status to a completed implant or adding a planned procedure to a P/I implant, a Procedure On Implant Warning displays. When prompted, click Yes to continue.
  5. If prompted with an Additional Tx Information window, complete the fields as necessary and click OK.
  6. Obtain approval and grading as necessary.

Adding conditions or materials to a patient’s record through the Chart Add tab is similar to adding treatment, however, it uses a list of procedures that are configured with a type of condition or material.

Note: Like procedure codes entered as findings, materials display on the chart with a status of E, and conditions display with a status of A.

To add a condition and material:

  1. Select a patient, open the EHR module, and click the Tx History or In Progress tab.
  2. Click the Create a new Record () icon to display the Chart Add tab.
  3. Click either of the following tabs:

    4. Note: The Expert and Diagnosis tabs can be ignored when adding conditions and materials.

    • Procedure:
      1. Select the Findings radio button to display the Material and Condition categories.
      2. Use the tree to navigate to the correct condition or material code.
      3. Double-click the procedure code to move to the Details sub-tab.
    • Details:

      • Note: Depending on information selected in previous tabs, several fields may be auto-populated.

      1. Complete the fields as necessary.
        2. Field Description
        Provider

        This is disabled, as a provider is not associated with conditions or materials.
        Date

        This defaults to the current date.

        If necessary, change the date to the appropriate date.
        Code

        The procedure code being entered.
        Desc. A read-only field that displays the description of the selected procedure code.
        Site

        Enter the site for the code.

        Tip: Use the odontogram to select multiple sites and add the selected condition to multiple teeth.
        Surfaces

        If applicable, enter the surfaces on the tooth that this procedure applies to.

        Tip: Use the odontogram to select surfaces across multiple sites and add the condition to multiple teeth/surfaces.
      2. Once all fields have been completed, click the Add Finding () icon to add the code to the patient’s record:
      3. Obtain approval as necessary.