Notation in OMS

Question 1

• Age and gender of patient first (identifiers)
• If speak any other langue document this next
• Then document where they are currently at (OMS clinic)
• Then document for what reason.

Answer 1

INTRODUCTORY STATEMENT

Question 2

• “Risks, Benefits, and Alternatives discussed with the patient regarding current treatment
(TE #14). Complications also discussed with the patient including but not limited to pain,
swelling, bleeding, infection, need for further surgery, sinus exposure, permanent or
temporary nerve damage, damage to adjacent structures, dry socket (as pt is a smoker
and diabetic). All questions answered to pattient’s satisfaction. Consent signed.”
• If extracting mandibular molar, remove sinus exposure (no sinus on mandible) but add
risk for jaw fracture

Answer 2

CONSENT DISCUSSION

Question 3

What vitals are recorded?

Answer 3

HR and BP

Question 4

• Goal is to write the exact steps performed during any procedure
• Write the note like you are addressing someone who works in the front office
• They may not know all the specific wording, but could be able to understand what occurred

Answer 4

PROCEDURAL NOTE

Question 5

• If no narcotics needed, i.e. for single tooth simple extractions, document no discharge (D/C)
prescription (Rx) given, but document ______ pain medication recommendations

Answer 5

over-the-counter

Question 6

• High potential for abuse
• No currently accepted medical use in treatment in US
• Lack of accepted safety for use of drug under medical supervision
• Examples: heroin, LSD, MDMA, mescaline, methaqualone

Answer 6

•Schedule I:

Question 7

• High potential for abuse
• Currently accepted medical use in treatment in US
• Or currently accepted medical use with severe restrictions
• Abuse may lead to psychological or physical dependence
• Examples: Methamphetamine, cocaine, fentanyl, hydro/oxycodone, and hydro/oxycodone
combinations, methadone, hydromorphone, Adderall

Answer 7

•Schedule II:

Question 8

• Low potential for abuse
• Has currently accepted medical use in treatment in US
• Abuse may lead to moderate or limited physical dependence or psychological dependence
• Examples: Benzodiazepines, muscle relaxers, tramadol, ambien

Answer 8

•Schedule IV:

Question 9

• Low potential for abuse
• Has currently accepted medical use in treatment in US
• Abuse may lead to moderate or limited physical dependence or psychological dependence
• Examples: Cough suppressants with codeine, pregabalin, lomotil

Answer 9

•Schedule V:

Question 10

What is max dose of tylenol that can be taken?

Answer 10

4 g

Question 11

What is max dose of ibuprofen that can be taken?

Answer 11

3.2 g