顎関節症患者のための問題志向型診療録の試作および検討

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Because of the need to make dental records from the standpoint of patients, we tried to make a problem oriented dental records (PODR) for the patients with temporomandibular disorders according to the thought of problem oriented system (POS). This PODR is based on the TMD patients protocol made by TMD Team Approach, Kyushu Dental College and referred to the PODR of UCLA Pain Management Center and the PODR of Kyushu Dental College Hospital. This PODR consists of five parts such as data base, problem list, initial plan, progressive note and discharge summary. The data base consisits of seven different sheets such as patient profile, history 1 and 2, examination 1, 2 and 3 and X-ray. Examination sheets include nine items of examination such as posture and facial symmetry, palpation, range of motion, TMJ noise, bite maneuvers, joint play, occlusion, guidance and soft tissue. The X-ray sheet includes four items of findings such as pantomogram, transcranial, orbit-ramus and MR images. The problem list sheet is the record of patients problem list, current medications, concomitant treatment and allergies. The initial plan sheet is the record of assessment (A), diagnostic information required (DxI), plan (P) and patient education (PtEd). The progressive notes sheet is recorded in accordance with the SOAP, and a medication log sheet is added with this sheet. The discharge summary sheet is the record of data base, initial problem list, treatment, current problem list, treatment outcome and summary. We would appreciate readers comments and complete this PODR.
九州歯科学会の論文
1999-04-25

顎関節症患者のための問題志向型診療録の試作および検討

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