The diagnostic procedures (history, physical examination, and imaging and laboratory studies) outlined in the preceding pages are designed to assist the dentist in establishing a plan of treatment directed at those disease processes that have been identified as responsible for the patient’s symptoms. A plan of treatment of this type, which is directed at the causes of the patient’s symptoms rather than at the symptoms themselves, is often referred to as rational, scientific, or definitive (in contrast to symptomatic, which denotes a treatment plan directed at the relief of symptoms, irrespective of their causes).
Like the diagnostic summary, the plan of treatment should be entered in the patient’s record and explained to the patient in detail (procedure, chances for cure [prognosis], complications and side effects, and required time and expense). As initially formulated, the plan of treatment usually lists recommended procedures for the control of current disease as well as preventive measures designed to limit the recurrence or progression of the disease process over time. For medicolegal reasons, the treatment that is most likely to eradicate the disease and preserve as much function as possible (ie, the ideal treatment) is usually entered in the chart, even if the clinician realizes that compromises may be necessary to obtain the patient’s consent to treatment. It is also unreasonable for the clinician to prejudge a patient’s decision as to how much time, energy, and expense should be expended on treating the patient’s disease or how much discomfort and pain the patient is willing to tolerate in achieving a cure.
The plan of treatment may be itemized according to the components of the diagnostic summary and is usually written prominently in the record to serve as a guide for the scheduling of further treatment visits. If the plan is complex or if there are reasonable treatment alternatives, a copy should also be given to the patient to allow consideration of the various implications of the plan of treatment he or she has been asked to agree to. Modifications of the ideal plan of treatment, agreed on by patient and clinician, should also be entered in the chart, together with a signed disclaimer from the patient if the modified plan of treatment is likely to be significantly less effective or unlikely to eradicate a major health problem.
Like the diagnostic summary, the plan of treatment should be entered in the patient’s record and explained to the patient in detail (procedure, chances for cure [prognosis], complications and side effects, and required time and expense). As initially formulated, the plan of treatment usually lists recommended procedures for the control of current disease as well as preventive measures designed to limit the recurrence or progression of the disease process over time. For medicolegal reasons, the treatment that is most likely to eradicate the disease and preserve as much function as possible (ie, the ideal treatment) is usually entered in the chart, even if the clinician realizes that compromises may be necessary to obtain the patient’s consent to treatment. It is also unreasonable for the clinician to prejudge a patient’s decision as to how much time, energy, and expense should be expended on treating the patient’s disease or how much discomfort and pain the patient is willing to tolerate in achieving a cure.
The plan of treatment may be itemized according to the components of the diagnostic summary and is usually written prominently in the record to serve as a guide for the scheduling of further treatment visits. If the plan is complex or if there are reasonable treatment alternatives, a copy should also be given to the patient to allow consideration of the various implications of the plan of treatment he or she has been asked to agree to. Modifications of the ideal plan of treatment, agreed on by patient and clinician, should also be entered in the chart, together with a signed disclaimer from the patient if the modified plan of treatment is likely to be significantly less effective or unlikely to eradicate a major health problem.