Dental Data Exchange
0.1.0 - STU1 Ballot

This page is part of the Dental Data Exchange (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Scenario 2 Dental to Medical Consult Note

Previous Page - Scenario 1 Medical to Dental Referral Note

Patient A sees Dr. Drew Dentist on February 16th for an urgent evaluation based on a referral from Dr. John M, his primary care provider. Patient A is a new patient at Dr. Dentist’s office, so a new patient record is created. Dr. Dentist reviews the risk assessment, the Dental Referral Note from Dr. John M, and the rest of the information that was pre-populated in the dental EHR. Dr. Dentist performs an oral evaluation and two PA radiographs. He identifies two areas of concern: patient has a significant, non-restorable caries lesion (decay) on the left lower back molar (tooth #18) with signs of infection, and early signs of decay on the right upper incisor (tooth #7).

Dr. Dentist recommends an extraction of the left lower molar (tooth #18) and restoration of the right upper lateral incisor (tooth #7) due to a caries lesion (decay). Dr. Dentist explains the importance of using a fluoride toothpaste when brushing twice daily with daily flossing, and of the need for bi-annual dental visits for examination and prophylaxis (cleaning).

Before Patient A leaves, the receptionist schedules an appointment for the extraction of tooth #18 on February 23rd, another appointment for restoration of tooth #7 on March 3rd, and a follow-up appointment for a complete examination, including radiographs and prophylaxis on March 10th.

Dr. Dentist reviews Patient A’s current medication list, notes an allergy to penicillin that is a counter-indication for his typical recommendation of amoxicillin, prescribes Erythromycin 500 mg every six hours for the infection and recommends alternating over-the-counter Ibuprofen and Acetaminophen for pain. Also, he generates a Dental Consultation Note back to Dr. John M with a summary of Patient A’s visit including the new prescription, planned procedures, future appointment dates, and patient specific dental goals.

Patient reports inability to chew on left side due to pain and sensitivity, a condition that has increased in severity in the two days since his medical appointment. Significant decay on the left lower second molar (tooth #18) with signs of infection. Early signs of a caries lesion (decay) on the right upper lateral incisor (tooth #7). Recommend an extraction of the left lower second molar (tooth#18) and a restoration on the right upper lateral incisor (tooth #7) due to a caries lesion.

Next Page - Scenario 3 Dental to Dental (Endodontist) Referral