1. Western Dental Orthodontic Documentation Calibration Left click to advance Corporate Offices

3. This training will assist Western Dental providers in mastering the Western Dental orthodontic documentation policies and procedures. Thorough documentation is necessary to ensure that we provide for the best interests of our orthodontic patients. Each office will be monitored for compliance with these policies and procedures. James F. Loos, D.D.S., M.S . Orthodontic Consultant Louis J. Amendola, D.D.S . Chief Dental Director Gary L. Dougan, DDS, MPH Dental Director

4. Left click (single) to advance all of the following slides after any arrow captions have scrolled in (Left click to advance)

5. The following are Western Dental Treatment Forms Please view the notations on each slide. All of the documentation demonstrated in this training is required for every patient .

6. Chart Jacket Estimated Completion date On the outside of the chart jacket, ensure that staff affix the start month/year and the estimated completion month/year so that progress towards completion can be easily monitored. Start Date

7. To be used on pages in chart, photos and X-rays Some of the stickers will have the word “Left” in the lower right corner. Those stickers are to be placed on panorex x-rays and FMXs to provide right-left orientation for the x-rays (in addition to identifying the patient). The “Left” designation must be oriented on or towards the left side of the patient in the X-rays. Stickers LEFT LEFT

8. Patient Information Form Staff ensures that this is filled out.

9. Health History Form Ensure that the patient is healthy enough for orthodontics as well as any necessary extractions or oral surgery procedures that may be required to complete orthodontic treatment. Review this form prior to examination of the patient. Make sure all lines have a box checked. Note any conditions requiring premedication or other pre-treatment actions.

10. Mark any positive answers with your initials and comments, as indicated . Your initials verify that you noted the medical condition. Your comments verify that you asked appropriate questions and investigated the condition to gain an understanding of the condition and its relevance to the planned treatment. Health History Form Add any further clarification to “yes” responses or a summary statement in this area

11. Health History Form Patient/Guardian’s signature/date Provider’s signature/date Update (annually or sooner, when indicated): must include date, any changes?, Dr signature, Dr number, and patient signature.

13. Initial Exam Form All items must be completed (numbers 1 to 24) Phases I or II and full or partial appliance List extraction or non-extraction or “ probably ---” List auxiliaries List # of months of active treatment

14. Diagnosis, Treatment Plan, and Perio Screening form Form 302b Under no circumstances may even a single bracket be bonded before this form is completed by the orthodontist and signed/dated by the patient/guardian !!

15. Exam Section Fill in Angle Class, OB, OJ, X-bites and any important diagnostic info. Perio Exam Section Document Perio Type and check the applicable perio conditions (calculus, hygiene, etc.) for all patients, even children. Sign and date. Treatment Plan Section Include extractions or non extraction, appliances, auxiliaries, goals, treatment steps and retainers. Also include any related general dentistry, oral surgery, or perio that will be required prior to, during or after orthodontic care (e.g. extractions, veneers to close spaces for small upper laterals, implants for missing teeth, etc.). Note when those treatments will be at additional expense to the patient. Circle “full” or “partial” and “phase” of treatment Doctor’s Signature, WD Number and Date! Parent/Guardian’s signature and Date!! Form 302b

16. IMPORTANT!! Patient/guardian signs here Any alternate treatment that is appropriate and has been offered or explained to the patient, i.e. extractions, surgery or similar is to be listed here If applicable: Also, list additional consent items such as “patient denied surgery, or denied extractions”. Any compromises/limitations in the planned treatment. For example, list compromises for treatment plans with lower incisor extractions (possible excess overjet), lateral substitutions (possible improper lateral disclusion and esthetic compromises), forced-eruption of impacted canines (possible damage to adjacent teeth roots), non-surgical compromises, etc. Treatment modifications or reviews are listed here Form 302b

17. Future Treatment Form Use the Future Treatment Form to advise the patient/guardian that general dental and oral surgery procedures are not included in the fees for orthodontic treatment and that those procedures should only be performed with the orthodontist’s authorization. Note any other treatments likely to be required here Patient or guardian signs/dates here

18. When Phase I treatment is planned, the Phase I Treatment Consent Form should be completed and signed/dated by the guardian prior to starting treatment. Phase I Treatment Consent Form

20. Office, chart number, and patient name Informed Consent

21. Patient’s or Guardian’s initials Always Patient’s or Guardian’s signature Always Doctor’s signature and WD Doctor Number, Always Witness signature Always Informed Consent Patient’s or Guardian’s initials, Phase I only

22. Compromised Treatment Disclosure The Compromised Treatment Disclosure should be completed and signed whenever a surgical treatment plan would be the preferred treatment plan but a non-surgical treatment plan is selected by a patient/guardian. This form evidences that the patient or guardian has been informed that the treatment outcome will improve the conditions but not reach all “ideal” treatment goals Signature of patient/guardian and date Signature of orthodontist and date

23. X X Check “Prophy” for all patients Check any other boxes, as appropriate. General dentist must complete, sign and date For all adults, check the area for perio evaluation by the general dentist X Cavity Clearance Form Check “Caries Check” for all patients Sign and Date !!

24. Circle appropriate teeth to be extracted Also, write out the names of the teeth to be extracted. Ensure that the correct teeth are identified, and highlight any request that is atypical in such a way to avoid any error by the surgeon (such as mismatched bicuspids). Extraction Order Form

25. Date Oral hygiene Instruction sticker (Completed by staff on or before the day of initial bonding) Records Approved sticker (Check all applicable boxes and sign/date) Oral hygiene grade, to be checked each visit Elastic pattern, size and instructions For the next visit, enter the time-needed units and appointment interval (1/4 means 1 time-unit in 4 weeks) Treatment Notes Form STOP! Check the records carefully to ensure they are of diagnostic quality! Make sure that photos are labeled with the patient’s name, date taken, office #, chart #, and name of the person who took them.

26. Wire type and size (RC is reverse curve of spee and COS is curve of spee) Next visit instructions Doctor’s initials and ID# Assistant’s initials Procedures performed Document any adverse conversations, cooperation problems, prescriptions, and all instructions! Always note just the facts. Do not record your “judgments” of previous treatment or treatment plans. Do not record “opinions” regarding the patient’s conduct in the office. Write just the facts, exactly as they occurred. Tell the story remembering that the patient or an attorney may someday read it. Treatment Notes Form Please Write Clearly

28. Initials ID# Ensure that Staff fills this out completely Encounter Form _Date__________ Fill in provider identification times and procedures

29. You must perform and document a Perio Evaluation every 6 months!!! Check the Perio Type Check applicable conditions Sign and date Perio Periodic Evaluation Form

30. You must perform a Progress Evaluation every six months Date Document the progress and cooperation in the applicable areas Sign/Date Progress Evaluation Form

31. Progress Review Form The Progress Review Form should be completed every six months during treatment. A copy can be given to the patient or guardian and a copy should be placed in the chart to evidence that cooperation issues were identified and addressed. Check a progress box Check all applicable boxes for each condition that is interfering with orthodontic treatment Note any additional comments including any agreements made regarding cooperation (e.g., “if oral hygiene does not improve by next visit, treatment will be discontinued and debanded”) Note whether there will be additional charges for treatment that extends beyond the planned finish date

32. Staff fills this in Financial Ledger Form

33. Make sure that a guardian or the patient (if 18 or older) signs and dates this form prior to de-bonding Debond or “Congratulations” Form

34. Retainers Form The Retainers Form has two copies, one for the patient and one for the chart. Ensure that the patient/guardian signs and dates the Retainers Form to evidence that instructions were given.

35. To be used whenever orthodontic treatment is discontinued prior to completion (reaching the goals of treatment) Patient/Guardian signs and dates Provider completes, signs and dates Request for Discontinuation Form Document when retainers are refused, and obtain an additional Patient/Guardian signature to evidence that retainers were offered and were refused

38. Both sides must be completed for patients who are transferring out ! AAO Transfer Form

39. Orthodontist signs Patient’s signature to release records AAO Transfer Form

40. Invisalign Forms

41. Invisalign Form

42. Invisalign Express