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Soft Tissue Examination

Soft Tissue Examination

How to record and read a soft tissue examination on the chart and in the note section.

The Soft Tissue Examination allows the practitioner to record any abnormalities during the assessment of the patient’s mouth.

 

1) Go to patient’s record -> Soft Tissue & Pathology tab.

 

2) Click the green plus arrow on the right hand side of the screen to add a new assessment.

3) The default choice is “Nothing Found” – in which case, you may press the save button to confirm that the assessment has been carried out and no abnormalities have been found.

4) This screen displays numerous tick boxes which represent different areas within the mouth. If an abnormality is found, tick this box to indicate such in the assessment. The option of “Requires Referral” may also be ticked.

5) Upon completion, the latest assessment will appear in the list on the right hand side of the screen, colour coded as follows:

 

  1. Green – nothing found
  2. Amber – one or more abnormalities ticked
  3. Red – one or more abnormalities ticked along with requires referral

6) Further details of the assessment can be recorded in the Pathology records.