Case note writing
( pemantauan klinikal
dan audit )
Case note in school
1. Chief complaint (C/O)
2. History of Present illness (when needed): HOPI
3. Medical History (MH) and medication
4. Allergy History (when needed) ( Allergy History )
5. Extraoral Examination (when needed) ( E/O )
6. Intraoral Examination (I/O) – LIST DOWN ALL TEETH INVOLVED
7. Diagnosis ( )
7. Treatment plan ( Tx plan ) –
NEED TO LIST DOWN ALL TEETH INVOLVED
8. Management ( Mx ) : Tx with codings WRITE DOWN TX WITH TOOTH SURFACES INVOLVED
WITH TREATMENT CODES/ No treatment required ( NTR ) / Case Complete (C/C)
9. Medication given (Rx)
10. Next Visit (N/v)
TREATMENT CODES/ KOD
RAWATAN
Case 1: all teeth sound and NTR
• 1. C/O - regular dental check up
• 2. HOPI - Nil
• 3. MH - Nil
• 4. Allergy History - Nil
• 5. I/O :
- No caries
- OH good
• 6. - Nil
• 7. Tx plan - regular dental check up / PRN
• 8. Mx :
• - OHI given
- patient reassurance
- NTR
- C/C
Case 2: with presence of caries/ findings
• 1. C/O - regular dental check up
• 2. HOPI - Nil
• 3. MH – Nil / any findings
• 4. Allergy History – Nil / any findings
• 5. I/O :
- Deep caries 17, 16 15
- caries 26, 25
- gross carious 14
- roots 55
- unerupted ??
- plaque ++ / BOP present / OH bad/ Calculus ++
- early lesion 11, 12 , 25
• 6. :
• - Dental caries ?? / gross carious ?? / impacted ?? / generalised gingivitis
• early carious lesion on ??
Case 2: with presence of caries/ findings
7. Tx plan :
- Filling 26, 25
- Scaling and polishing
- XLA on 14
- KIV XLA/ RCT 17, 16 ,15
- Fluoride varnish FV 11, 12
- PRR 25
8. Mx :
- write in usual way
9. N/v : Follow Tx plan
Case note in clinic
• 1. Chief complaint (C/O)
• 2. History of Present illness: HOPI
• 3. Medical History (MH) and medication
• 4. Allergy History ( Allergy History )
• 5. Extraoral Examination (when needed) ( E/O )
• 6. Intraoral Examination (I/O) – NEED TO LIST DOWN TEETH INVOLVED
• 7. Investigation Findings (Ix)
• 7. Diagnosis ( )
• 7. Treatment plan ( Tx plan ) – NEED TO LIST DOWN TEETH INVOLVED
• 8. Management ( Mx )- WRITE DOWN TX WITH TOOTH SURFACES INVOLVED
WITH TREATMENT CODES
• 9. Medication given (Rx)
• 10. Next Visit (N/v) – NEED TP LIST DOWN TEETH INVOLVED
TREATMENT CODES/ KOD
RAWATAN
Case note in clinic/ school
Glossary : Maksud setiap short form
(abbreviation)
NO Abbreviation Meaning
1 C/O Aduan utama pesakit ( dalam perkataan pesakit sendiri)
(Chief Complaints) I.e. : “sakit gigi atas sebelah kanan” / “gusi bengkak”
2 HOPI Penerangan kronologi tentang perkembangan penyakit pesakit dari simptom pertama hingga sekarang
(History of presenting illness)
3 MHx / MH Sejarah perubatan pesakit yang merangkumi sejarah pembedahan lepas, sejarah perubatan keluarga,
(Medical History) sejarah sosial, alahan dan ubatan yang diambil oleh pesakit termasuk yang sudah berhenti atau
diberhentikan doctor.
4 NKMI Tiada penyakit perubatan yang diketahui pesakit. Abbreviation ini boleh digunakan selepas MH/Mhx
( No known medical illnesses) jikalau pesakit tiada penyakit yang diketahui I.e. : Mhx : NKMI
5 NKDA Tiada alahan ubatan yang diketahui pesakit. Abbreviation ini boleh digunakan selepas MH/Mhx jikalau
( No known drug allergies ) pesakit tiada alahan ubatan yang diketahui I.e. : Mhx : NKMI , NKDA
6 E/O Pemeriksaan luar mulut. Nyatakan jikalau ada. I.e.: E/O : right cheek swelling
( Extraoral Examination )
7 I/O Pemeriksaan dalam mulut. Nyatakan jikalau ada. I.e: I/O : poor OH, calculus ++ , carious 46 (o) 36 (do) ..
( Intraoral Examination )
8 NAD Tiada abnormal dikesan. Abbreviation ini boleh digunakan selepas E/O dan I/O jikalau tiada abnormal
( No Abnormality Detected ) dikesan semasa pemeriksaan I.e. : E/O : NAD / I/O : NAD
9 TOI / SOC Dicatat pada bahagian pemeriksaan intraoral / extraoral
(Tooth of interest / site of I.e. : I/O : TOI 36 – occlusal caries /
complaint) I.e. : E/O : SOC – left upper side of teeth
Glossary : Maksud setiap short form
(abbreviation)
NO Abbreviation Meaning
1 Ix Dicatat jikalau siasatan khusus untuk penyakit dikesan dijalankan. ( IOPA/EPT/OPG etc )
( Investigations ) I.e. : Ix : IOPA done 36 – noted deep caries with periapical lesion
2 / Ddx Diagnosis penyakit , I.e. : Ddx : 36 - dental caries / : 36 – dental caries
( Diagnosis)
3 Tx Pelan rawatan.
( Treatment Plan) I.e. : Tx : 1. Filling 36 (o) 46 (do) 2. full mouth scaling etc
4 Mx Rawatan pada hari ini.
( Management ) I.e. : composite filling done on 36 occlusal. Full mouth scaling done.
5 Rx Preskripsi ubat. Juga dicatat dalam bahagian Mx.
( Prescription ) I.e. : Mx : 1. Full mouth scaling + OHI
2. Rx : 0.2% Chlorhexidine mouthwash BD x 2/52
6 BD / q12h Dua kali sehari / setiap 12 jam
TDS / q8h Tiga kali sehari / setiap 8 jam
Qid / q6h Empat kali sehari / setiap 6 jam
PRN “in circumstances” – Bila perlu
( Pro re nata )
THANK YOU !!!
