Form 23 - Patient Management Plan

Patient Management Plan

Use Patient Barcode Label
Given Name: ______________________
Surname: ______________________
DOB: ______________________
TEMP: ______________________

Clinician: ______________________
Clinician ID: ______________________
Date: ______________________

Management Priorities¹

• Relief of pain
• Address the reason for attendance/presenting complaint (Form 21)
• Life threatening problems (e.g. OM, OP, OS, infections)
• Inflammatory conditions (e.g. Endo, Perio, OS, infections)
• Caries management (includes prevention and restorations)
• Assessment and replacement of restorations for non-carious reasons (e.g. fracture, aesthetics)
• Reassessment
• Repositioning (orthodontics if required)
• Prosthodontics (indirect restorations, dentures, implants, splints)
• Review, reassessment and ongoing care (includes regular debridement, follow-up of endodontic and prosthodontic treatment)

PMP to Include

• Order of procedures (tooth by tooth) according to priority
• Appointment outline – time, procedure, proposed date
• Further investigations/referrals required

Patient Identification

Relief of Pain

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Supervisor’s signature for palliative treatment by student: ______________________

Clinician Code: ______________________

Address the Reason for Attendance / Presenting Complaint (Form 21)

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Clinical Management Components

• Caries management (includes prevention and restorations)
• Assessment and replacement of restorations for non-carious reasons (e.g. fracture, aesthetics)
• Reassessment
• Repositioning (orthodontics if required)
• Prosthodontics (indirect restorations, dentures, implants, splints)
• Review, reassessment and ongoing care (includes regular debridement, follow-up of endodontic and prosthodontic treatment)

Plan Authorization²

Patient Management Plan Authorised by: (for student clinicians) Clinician ID: Date:

I understand and agree to the suggested treatment plan Parent/Guardian Signature: Parent/Guardian Name: Date:

Footnotes

1. Original PDF page 1: Form 23 - Patient Management Plan, p.1 ↩

2. Original PDF page 2: Form 23 - Patient Management Plan, p.2 ↩