Checklists and Forms for Diagnosis and Treatment Planning

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Diagnosis and Treatment Planning Study Packet- This packet of checklists, forms, letter samples, and other documents is essential to organizing the diagnosis and treatment planning process. Use it when viewing the Diagnosis and Treatment Planning Process Course.

Treatment Record- This form is described in the Treatment Record Course. During the Diagnosis and Treatment Planning Session, the doctor adds data to this form for a quick reference for the whole team to understand the initial status of the patient, the treatment plan, alerts, and the treatment delivered.

Diagnosis and Treatment Planning Worksheets- These forms are useful when diagnosing and selecting treatment options for a more complicated patient. Sections for writing a problem list and potential solutions, a diagnosis, treatment goals, and listing treatment options including their advantages and disadvantages, are provided on the form.

MS Word  Document

Diagnosis Form and Consult Checklist - This form is used to diagnose an average case and list the items that must be discussed at the Treatment Consult.

MS Word  Document

Detailed Treatment Plan Worksheet- This form is useful to help the doctor write a detailed treatment plan that will be a communication tool for the whole team about each step in the delivery of the patient's treatment. Instructions for writing a detailed treatment plan are included in the Diagnosis and Treatment Planning Study Packet.

MS Word  Document

Packet of Consult Letters and List of Risks- This packet includes all of the Summary Consult Letters listed below that are given to the patient at the Treatment Consult. The doctor fills out these forms when working up a patient. Also in this packet is the List of Risks associated with treatment that the doctor also completes during the work up of the patient. These forms may be edited to fit the needs of the practice.  

MS Word  Document

List of Possible Risks- This form lists most of the risks that can occur with orthodontic treatment that should be discussed with the patient. This form may be edited to fit the needs of the practice.

MS Word  Document

Consult Letter Template- This Excel Spreadsheet lists mosts of the problems that may need correction with orthodontic treatment, lists a selection of treatment plans, and calculates the final fee arrangements. It is printed and given to the patient/parent at the Treatment Consult.

MS Excel Spreadsheet

Comprehensive Treatment Summary For The Patient- This summary is given to the patient/parent at the Treatment Consult. It summarizes the findings from the records, states that comprehensive treatment is needed for a specific number of months, and specifies the fee arrangements.

MS Word Document

Phase I Treatment Summary For The Patient- This summary is given to the patient/parent at the Treatment Consult. It summarizes the findings from the records, states that Phase I treatment is needed for a specific number of months, and specifies the fee arrangements.

MS Word  Document

Phase II Treatment Summary For The Patient- This summary is given to the patient/parent at the Treatment Consult. It summarizes the findings from the records, states that Phase I treatment is needed for a specific number of months, and specifies the fee arrangements.

 MS Word  Document

Progress Consult Summary For The Patient- This summary is given to the patient/parent at the Progress Consult following Phase I or after a reassessment during comprehensive treatment. It summarizes the findings from limited records, states the treatment recommendations. This summary is useful for patients who are not on schedule.

 MS Word  Document

Diagnosis and Treatment Planning Process Checklist- This checklist summarizes all of the steps in completing all of the paperwork for a Diagnosis and Treatment Planning session as described in the online course. If this checklist is followed, each patient will be enrolled in treatment with realistic expectations, a treatment plan will be used to guide the treatment of the patient, and treatment delivery will be completed on time for the agreed upon fee.

Acrobat Reader - To download, view and print the PDF Checklists you need to have Adobe Acrobat Reader Installed.