Charting a quick exam

You can quickly chart a patient's conditions, existing treatment, and treatment needs during a full evaluative examination.

Note: Access to the quick exam features is controlled by the same security rights as those for dental charting and managing patient procedures.

To chart a quick exam

How to get there
1. If the correct patient is not already selected, use the Patient Search box to access the patient's record.
  
  Note: You can include inactive patients in the search results by setting the Include inactive patients switch to On.
2. On the Patient menu, under Clinical, click (or tap) Quick Exam.
  
  The patient's clinical record opens with the Quick Exam tab selected.
On the Quick Exam tab of a patient's clinical record, in the Provider list at the top, select the provider who you want to associate with conditions, existing work, and treatment-planned procedures that you chart during the quick exam.

Notes:
- Only providers who have access to the current location and who are flagged as charting providers are available. Also, the provider who is selected by default is determined by the current location's Default procedure provider setting.
- At any time during the quick exam, you can change the provider as needed before charting a condition or procedure. Changing the provider may change which options are available in the Available procedure search list and, consequently, may change which procedures are available in the Treatment Plan list.
Select one or more teeth.
Do any of the following as needed:
- Change the dentition.
  - Click (or tap) either the Permanent Dentition or Primary Dentition button in the Conditions column header. The button that is available depends on the current dentition of the selected tooth.
    
    Note: To change the dentition of all the teeth to primary or permanent, click (or tap) Clear Selected to deselect all teeth before attempting to change the dentition.
- Chart a condition.
  Click (or tap) a condition in the Conditions list. The posted condition is now pinned to the top of the list (and is visible while the current tooth is still selected). Also, the tooth now has a green box to indicate that a condition is associated with that tooth.
  
  Tip: To search for a condition that is not a favorite or to filter the list, click (or tap) the column's Search button , and then begin typing part of a SNODENT code, SNOMED CT code, or description in the field that appears.
  
  Notes:
  - If you are posting a condition that requires a surface to be selected, in the pop-up box that appears when you click (or tap) the condition, select the appropriate surfaces, and then close the pop-up box.
  - If you are posting a condition that requires a direction to be selected, in the pop-up box that appears when you click (or tap) the condition, select the appropriate direction, and then close the pop-up box.
  - If clinical decision support (CDS) is turned on and procedure codes have been associated with a condition, after you select that condition, the potential treatment appears at the top of the Treatment Plan list, so you can quickly treatment plan a procedure relevant to the diagnosis.
    
    If there is a procedure in the Potential Treatment (Clinical Decision Support) area of the Treatment Plan list that you want to use to treat the selected condition, and if the potential treatment requires treatment areas (such as tooth numbers and surfaces) that the condition does not, you can specify those treatment areas when you treatment plan the procedure, just like any of the other procedures in the Treatment Plan list.
  - To delete a posted condition, click (or tap) the corresponding Unpin button , and then click (or tap) Delete.
  - To add notes or specify surfaces for a posted "watch tooth" condition, click (or tap) the condition's surfaces diagram to view the corresponding pop-up box. Enter text in the Notes box, or select the appropriate surfaces. Then, close the pop-up box.
- Chart existing work.
  Click (or tap) a procedure in the Existing Work list. The posted procedure is now pinned to the top of the list (and is visible while the current tooth is still selected). Also, the tooth now has a blue box to indicate that an existing procedure is associated with that tooth.
  
  Tip: To search for a procedure that is not a favorite or to filter the list, click (or tap) the column's Search button , and then begin typing part of a procedure code or description in the box that appears.
  
  Notes:
  - The procedures that are available depend on if a tooth is selected. Also, only procedures that have been marked as favorites appear in the list.
  - If you are posting a procedure that requires a surface to be selected, in the pop-up box that appears when you click (or tap) the procedure, select the appropriate surfaces, and then close the pop-up box.
  - To delete a posted procedure, click (or tap) the corresponding Unpin button , and then click (or tap) Delete.
- Treatment plan a procedure.
  Do the following:
  1. Procedures appear in the Treatment Plan list according to the selected filter. Click (or tap) the column's Search button to change the procedure filter.
    
    Select one of the following filters from the list next to the Available procedure search box as needed:
    - Carrier procedures - If the patient has any active insurance plans attached to his or her record, and if the selected Provider is contracted with any of the patient's carriers, Carrier procedures is selected by default. With this option selected, only the carriers' allowed procedures are available.
    - Location procedures - If the patient is not covered by an insurance carrier that the provider is contracted with, Location procedures is selected by default. With this option selected, only the location's allowed procedures are available.
    Note: Carrier procedures is available only if the patient has any active insurance plans attached to his or her record, and if the selected Provider is contracted with any of the patient's carriers. Location procedures is available for any patient.
  2. Click (or tap) a procedure in the Treatment Plan list.
    
    Important: If you chart a multi-code that includes some procedures that are not allowed by the the location or any of the patient's carriers, those procedures will not be posted.
    
    The posted procedure is now pinned to the top of the list (and is visible while the current tooth is still selected). Also, the tooth now has a red box to indicate that a treatment-planned procedure is associated with that tooth.
  Tip: To search for a procedure that is not a favorite or to filter the list, click (or tap) the column's Search button , and then begin typing part of a procedure code or description in the box that appears.
  
  Notes:
  - The procedures that are available depend on if a tooth is selected. Also, only procedures that have been marked as favorites appear in the list.
  - If you are posting a procedure that requires a surface to be selected, in the pop-up box that appears when you click (or tap) the procedure, select the appropriate surfaces, and then close the pop-up box.
  - To delete a posted procedure, click (or tap) the corresponding Unpin button , and then click (or tap) Delete.
  Notes:
  - If you chart a tooth-specific condition (with one or more teeth, but not a whole quadrant or arch, selected) and then treatment plan a procedure for a quadrant or an arch, Dentrix Ascend will automatically assign the correct treatment area for the posted procedure.
  - If you chart a mouth-specific condition (with no teeth selected) and then attempt to treatment plan a procedure for a tooth, a quadrant, or an arch, a message appears and asks you to select the correct teeth and then try to post the procedure again.
  - If you chart conditions and then, with the same tooth (or teeth) selected, treatment plan procedures to treat those conditions, the conditions (diagnoses) are automatically associated with those procedures. When you complete the procedures, Dentrix Ascend prompts you to choose which, if any, of the associated conditions you want to mark as Treated. Also, when you create a claim or pre-authorization for the procedures, the corresponding ICD-10 codes are automatically attached to the claim or pre-authorization.
Create a clinical note as needed.

Notes:
- When you create a clinical note with a tooth selected, that tooth will be associated with the clinical note by default. To create a clinical note that is not tooth specific, click (or tap) Clear Selected to deselect all teeth before attempting to add the clinical note.
- After you create the clinical note and close the Add Clinical Note dialog box, you are returned to the quick exam.
Repeat steps 2 - 4 as needed for each tooth.

Tips:

At any time during the quick exam, you can view what you have posted so far today without having to select each tooth individually to see the pinned items and without having to navigate to the progress notes. Click (or tap) the Conditions, Existing Work, and/or Treatment Plan column header names. A column header name is a link that you can click (or tap) only if a corresponding condition or procedure has been posted today as indicated by the number in parentheses after the column header name.
To switch back to viewing a column normally, click (or tap) the column header name or the Back link.