What forms work best for you for recording exam data in your practice?

In the Spear workshops, we use forms that establish a method for us to teach a thorough muscle and joint exam and to work through the EFSB process. However, they may or may not be best for you in your practice.

I have been asked on several occasions to share the forms that I have developed to use in my practice, so you may find them attached in Word documents so that you may modify them as you see fit for your use--freely and at your own peril. I have developed them over the years based on information that I have unabashedly stolen, pilfered, plagiarized, and acquired over a variety of continuing education courses, articles, texts, colleagues, etc. Therefore, I take credit for none of them except to take a bit of pride in condensing them to one form formats to easily scan into my Dentrix Document Center and to quickly refer to during treatment visits. You will see that they are arranged in SOAP format. I have found that physicians "get it" when I fax them my exam findings, and the sleep form has been accepted by insurance companies without difficulty when submitting for sleep appliances.

There are three forms: comprehensive exam, sleep, and TMJ Problem-Focused exam. I use the one best suited for the particular exam. The forms are not all-inclusive and require additional forms where needed. For example, the periodontal record is on another form. If I want a more detailed record of the muscle exam, I will use the Spear form. If I want a more detailed pain diagram, I will give the patient a larger print-out of the pain diagram in the upper right portion of the form. The point is, these forms may lead to the need for other forms.

You will see that the muscle and TMJ evaluation section is different from what we learn at Spear. It is taken from the evidence-based NIH project published in 2013 (also attached). I would recommend that you peruse this daunting document because there is good information here, like when a particular imaging modality is recommended for TMJ evalulation. I use this format because it is easier to use during an exam in my practice than recording finding from all of the muscles. Note that it requires you to record whether pain is familiar to the patient (experienced during the past 30 days) or only ellicited during the exam and whether TMJ findings are limited to the clinician's observations or if the patient is aware of them.

The muscle and TMJ diagnoses are also those of the TMD/DCM document as well and reflect current terminology as established by the American Board of Orofacial Pain.

Lastly, remember that if there are unremarkable findings, it is not required to record anything. This legal concept is called "charting by exception." Please review my Spear Digest pieces on this topic:

https://www.speareducation.com/spear-review/2016/07/making-sense-of-the-clinical-record

https://www.speareducation.com/spear-review/2016/11/recording-the-clinical-record

Please feel free to ask any questions you may have about how to use these forms.

If you have particular forms you use that work well for you, please share them here so other may benefit from them.

Thank you!

Kevin