Dental Data Exchange
1.0.0 - STU 1

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## Example Bundle: Complete Dental Consult Note Document Bundle example

## Allergies and Intolerances Section

Substance | Overall Severity | Reaction | Reaction Severity | Status
Penicillin G (Ingredient) | Mild | Skin rash | Mild | Active

## History of Present Illness Section

The patient has not visited a dentist or received fluoride treatments in the past four years while away at college

## Problem Section

Mild, Hypertension

Type 1 diabetes

Dental caries

Unable to chew

Teeth covered in plague

Toothache

Chronic periodontitis

Infection of tooth

At high risk for dental caries (finding)

## Medication Section

Medication | Directions | Start Date | Status | Indications | Fill Instructions
erythromycin 500 mg | Take 1 tablet every six hours X10 days |  | Active |  |
ibuprofen (OTC) 200 mg tab | Take 2-3 tablets every 8 hours as needed for pain | Take 2-3 tablets every 8 hours as needed for pain |  | Active |  |
acetaminophen (OTC) 325 mg | Take 2 tablets every 4-6 hours as needed for pain |  | Active |  |
Lisinopril 10 mg tab | 1 tab once a day |  | Active |  |

## Assessment Section

Patient reports inability to chew on left side due to pain and sensitivity, a condition that has increased in severity in the two days since his medical appointment

Significant decay on the left lower second molar (tooth #18) with signs of infection

Early signs of a caries lesion (decay) on the right upper lateral incisor (tooth #7)

Recommend an extraction of the left lower second molar(tooth #18) and a restoration on the right upper lateral incisor (tooth #7) due to a caries lesion

## Immunizations Section

Vaccine | Date | Status
--- | --- | ---
Hepatitis B vaccine | January 4, 2020 | Completed

## Medical Equipment Section

Device Type | Procedure | Implant Date
--- | --- | ---
Insulin Pump | Insertion of insulin pump (procedure) | November 3, 2013

## Plan of Treatment Section

Date | Code | Description | Mouth Location
--- | --- | --- | ---
Feb 23, 2020 | D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | Tooth #18
Mar 3, 2020 | D1352 | Preventive resin restoration in a moderate to high caries risk patient-permanent tooth | Tooth #7
Mar 10, 2020 | D0150 | comprehensive oral evaluation - new or established patient | N/A
Mar 10, 2020 | D1110 | Prophylaxis - Adult | N/A
Mar 10, 2020 | D0210 | Full mouth radiographic survey | N/A

## Procedures Section

Date | Code | Description | Mouth Location
--- | --- | --- | ---
Feb 16, 2020 | D1206 | topical application of fluoride varnish | N/A

## Reason for Visit Section

Patient referred for evaluation and treatment for toothache lower left

## Social History Section

Social History Element | Description | Effective Dates
Smoking Status - Meaningful Use | Never smoked tobacco | Feb 14, 2020
Highest Education Level | College Education | 2005/05/01 - 2010/02/28
Employment | Accountaint, Full Time | 2005/05/01 - 2010/02/28

## Vital Signs Section

Observation Type | Value | Units
--- | --- | ---
Body Temperature | 99 | [degF]
Heart Rate | 82 | /min
Blood Pressure - Diastolic | 80 | mmHg
Blood Pressure - Systolic | 120 | mmHg

## Instructions Section

Patient educated on the benefits of using a fluoride toothpaste, daily flossing, and bi-annual routine dental cleaning visits.

## Payers Section

Aetna Comprehensive Medical /Dental Insurance

## Dental Findings Section

Finding Type | Value | Location
--- | --- | ---
Problem | Dental Caries | Tooth #18
Problem | Infection of Tooth | Tooth #18
Problem | Dental Caries | Tooth #7
Result | Overjet | 3mm