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Evaluation: Patient Requiring a Limited Evaluation of a Specific Problem

(Adopted 1994, Revised 1997)

Preamble (Adopted 1994)

The key element in the design of this set of parameters for limited evaluation of a specific problem is the professional judgment of the attending dentist, for a specific patient, at a specific time.

The patient's chief complaint, concerns and expectations should be considered by the dentist.

The dentist should perform a limited evaluation when indicated in his or her professional judgment.

The patient should be provided with appropriate information by the dentist about the diagnostic procedure(s) to be performed prior to giving consent to a limited evaluation.

Any evaluation performed should be with the concurrence of the patient and the dentist. If the patient refuses diagnostic procedures, the dentist may decline to evaluate the patient. If the patient insists upon diagnostic procedures not considered by the dentist to be necessary for evaluation, the dentist may decline to provide those procedures.

Medications should be prescribed, modified and/or administered by the dentist to dental patients whose known conditions would affect or be affected by diagnostic procedures provided without the medication or its modification. The dentist should consult with the prescribing health care professional(s) before modifying medications being taken by the patient for known conditions.

In the process of diagnosis and treatment planning, the attending dentist should review the accuracy of the data collected as part of patient evaluation.

The dental and medical histories should be considered by the dentist to identify medications and predisposing conditions that may affect the prognosis, progression, and management of the oral health condition. (See: JADA article: New national guidelines on hypertension.)

The behavioral, psychological, anatomical, developmental and physiological limitations of the patient should be considered by the dentist in performing the limited evaluation and in developing the treatment plan.

The dentist should attempt to manage the patient's pain, anxiety and behavior during evaluation to facilitate safety, efficiency and patient cooperation.

A limited examination should be performed by the dentist to diagnose and determine the treatment for a specific oral health problem.

Radiographs or images of diagnostic quality should be obtained. The number and type of radiographs or images required to provide the information needed for diagnostic purposes will vary according to the needs of the individual patient and should be determined by the attending dentist. (See: Professional Topic "Radiography/X-Rays," The Selection of Patients for Dental Radiographic Examinations [PDF].)

Additional diagnostic tests relevant to the evaluation of the specific oral health problem of the patient may be performed and used by the dentist in diagnosis and treatment planning.

When the dentist considers it necessary, (an)other health care professional(s) should be consulted to acquire additional information.

The dentist should refer the patient to (an)other health professional(s) when the dentist determines that it is in the best interest of the patient.

Relevant and appropriate information about the patient and any necessary coordinated treatment should be communicated and coordinated between the referring dentist and the health professional(s) accepting the referral.

The patient should be informed of the findings and observations of the limited evaluation.

The dentist may take this opportunity to emphasize the prevention and early detection of oral diseases through patient education in preventive oral health practices, which may include oral hygiene instructions.

The dentist may recommend that the patient return for further evaluation. The frequency and type of evaluation(s) should be determined by the dentist, based on the patient's risk factors.

The health history, and the findings and observations of the limited evaluation and general health assessment, including counseling and recommended preventive measures, as well as consultations with, and referrals to other health professionals, should be included in the patient's dental record.