Hi, I'm Trish Braga, and I'm Director of Education for the AADSM, and the AADSM has been working on a lot of documents to help everybody get set up in their practice management systems, and notably one of those is a set of soap note documents, and they bear a little bit of explanation. So I just want to talk you through how I believe these soap notes are designed to be used. I hope it gets you thinking about how you would use it yourself in your own practices, because I really think it speeds up practice management setups when you're building your systems. So let's just talk through these soap note documents that are available to members of the AADSM. Now, starting with how we're going to refer to some of these visits, there's some confusion about what to call these visits, and so just so there's no confusion as you're looking at these soap notes and what they're called, I want you to know that some of these phrases that we use in both the Mastery Program and in the Practice Management Program are based on the consensus papers and the standards papers that the AADSM has in its files, and sometimes these phrases confuse me, so I just thought we'd spend just a second talking about what some of these phrases mean. When we talk about risk assessment, we're really talking about anything that I would typically call a screening tool or a screening visit, a screening document, a screening soap note, and that's all for risk assessment. That's all before you begin the process of fabricating an oral appliance, or the next step, which would be initiation of treatment. When you think about what goes into these four buckets, I think anything that has to do with delivery is pretty obvious, since delivery of a device is usually one visit, but we've also bundled calibration and follow-up into a big bucket, so included in that would be any objective testing processes that you had or documents that you created for that, and another term for follow-up, either short or long term, could also be called monitoring. You might hear a lot of different words or phrases for these, but I'll go into a little bit more detail about each of these as I explain the soap note documents. Let's start out with risk assessment or screening, and what we do with that, of course, is we gather subjective data, which we're going to put down into our soap document, and the sources for that information are pretty broad. It can happen with every patient encounter. It can happen at the front desk with your admin staff. A very typical place for screening to happen in a general practice would be in the hygiene department. It could be chairside during a procedure, and when we talk about who's doing that, I'm going to refer to the dentist as a part of the team. It's just a different department within that team, so when I think about who's gathering this subjective data, it's everybody on the team, and it can be done with forms, paperwork. It can be done with screeners, questionnaires, but it also can be done just when you're talking to a patient. It can be a chairside assistant talking to a patient about their plans for the holidays, and it can evolve into sleep and sleep complaints, and so screening can happen at any time, any point of time you're having a conversation with a patient, and of course, when we are talking about the subjective part of risk assessment, we're talking about symptoms, chief complaint, and other complaints, and we're talking about signs, subjective signs, things you would find in the medical history, the prescriptions, the review of systems, and so on. Now, there is also an objective component, of course, to risk assessment, and those are the signs. You know, how does a patient look? What's their posture like? How heavy are they? What's your impression of their energy level or their general attitude? Are there bags under their eyes? And again, this can happen really with almost any visit, even virtual encounters, and I'm thinking of telehealth here, and again, it's almost every team member. Probably when we're doing objective assessment, it's less so at the front desk, so it would be less of the admin team unless they were brought into the back for sleep interviews, and it's, of course, the physical evaluation and the examination. Physical evaluation would be, in my opinion, it would be what I can see looking at a person that's sitting three feet away from me versus when I'm actually doing an exam and touching a patient, and maybe going intra-orally and looking for some functional testing as well, tongue position, swallow, nasal breathing, or mouth breathing, and so on. So again, we're talking about soap note documents here, so when we talk about risk assessment, we need to think about the assessment and the plan. The assessment can always be initiated by a well-informed team member, but the final decision really needs to be the dentist, of course, the treating dentist, and that might look like something, the assessment on a risk assessment might be suspicion of sleep-related breathing disorder. It might be in a patient who has already tried CPAP or some other procedure that they are untreated or undertreated. Maybe they're using CPAP only once or twice a week. Maybe they only use it when they're sharing a bedroom with their spouse, and then I would also call assessment, how much does this patient know about their disease process or the disease in general? So that would be their disease literacy, and then the other piece of that that is really important is how ready are they to take action? When you assess that, then you know what your plan should be. A patient who is not ready to take the next step should not have a plan that says refer to physician. Maybe that patient's plan should be agree to continue the conversation at the next re-care appointment or something of that sort. So the plan and the assessment go together, and that is really in the dentist's purview. So just for a minute, think about how you do your, or how you're intending to do your setup for your dental sleep practice. Are you going to be electronic or paper? Now I would give you this advice without you asking for it. It's free. If you have electronic dental records, then I would set as my goal, if I were you, to also have electronic sleep records, and the purpose of these soap notes is for you to be able to drop this into any of your systems. Dentrix is a very common system, PracticeWorks, EagleSoft, and then there are many, many web-based programs now that really weren't around that much when I had a clinic, and those are even more malleable and customizable, and these kind of soap note documents work really well in those systems. So I hope to give you some idea how to do that right now today, but in any case, however you decide to do that, everything I'm talking about here in these documents can be done either with a paper form or an electronic form. So just for explanatory purposes, let's say that we are going to set up an electronic system. Well, in every practice dental software, there you have an opportunity to create a soap note. I know you do that in your hygiene documents, and when a patient comes back for their next hygiene visit, your hygienist copies and pastes data they collected at the last six-month visit and brings it forward into today's visit, and that's exactly how these are designed to be used. Now, when you open these soap note documents, it's, well, it's all one document, but you can see it's many, many pages, and the way that it's laid out is it starts with the screening consultation soap note in an instructional fashion, which we see here on the left of this slide, and that's immediately followed by the screening consultation soap note as a sample to give you an idea of how it should be filled out or what it could potentially look like. Now, I'm going to zoom in on the sample just so I can point to it a little bit or so you can see it better as I'm talking about it. Now, the collection of this, of course, as we, I think we talked to or I alluded to a little bit before, is primarily through your forms, whatever screeners you're looking at, and your sleep-focused interviews, so any conversations that you're having, and if you are not using a screening form and then following it up with questions, I would recommend that you do that starting right away because that's how you get a patient to start talking about their symptoms, and you'll uncover what would potentially motivate them to go through the work and expense of being treated with an oral appliance, and you can see there's a cheat complaint. There are medications, not every medication, just medications that kind of give you a clue that this patient, what's a sign and symptom of disease, so it's going to be heart medication, for example. It could be GERD medication, metabolic medication for sure, allergies to metals because a metal allergy will come in handy later when you're designing a device and so on you can see, I don't need to read these to you, but you can see it's a very comprehensive list. Now in your mind, maybe it's not comprehensive enough, but at a screening visit, when you are assessing risk, it might seem like it's too much. These are not designed to be used without you considering exactly how you want to use them in your practice. And this is where you do put your heads together with your colleagues, your team members, and you decide how you want to screen. But before you start removing too many of these for the screening process, think about how you want to copy and paste this going forward. So you might include all of this in your risk assessment appointments, whether they be in hygiene, maybe they are even initiated at the front desk, on the phone, the document starts to be populated, but maybe it's not completely filled in. And that's okay, because you want to copy and paste it moving forward with as much data as you want to have available on your comprehensive exam. And then also arguably on your follow-up visits when you are assessing improvement in a patient's outcome with their oral appliance therapy. So let's imagine a hygiene visit, because this is very common. The hygienist would complete the subjective and objective part either completely or just briefly. You know, we know our hygienists do not have a lot of time, so maybe it would look something like this where the chief complaint is filled in and the medications that are red flags are filled in, and maybe a previous intervention, maybe a patient had already tried CPAP, for example, but had never been treated with an oral appliance. And then maybe very likely an Epworth might be administered by the hygienist or a stop bang, and the hygienist might take a look at the neck circumference and the class of mull and poly. And then filling out all the regular charting in the dental chart, the electronic health record that the hygienist would normally do. Then the dentist comes in the room, the dentist may add data here into the soap note or may not, and then come up with an assessment and plan. Now, this is incomplete, of course, but it certainly may be enough to take the action step that's required for this patient. For example, a referral to a physician for a consultation and potential diagnosis. So now let's shift on to what we consider to be the oral appliance therapy initiation steps. In some offices, this might be done all in one visit. In other offices, it might be a little different. It could be broken down. For example, a dentist might do the comprehensive examination and then have a treatment consultation and a financial arrangement, a discussion of a informed consent. And then once the patient agrees, schedule them at a later time for the records to actually start the process of making the device. However your office does it, it doesn't matter. All of those things are considered oral appliance treatment initiation. And if you in your office do it with several visits, which I did primarily, then you want that soap note to continue through and be very uniform as you go through those visits so that you are not having to recreate it every time. It should be a simple copy and paste forward either in your electronic record where copy and paste works the best, or you could be just using that same paper form moving forward into all these visits if you are gonna use paper documents. So this would be the part, for example, that I would copy and paste forward from one appointment to the next. This could have been completely or incompletely filled out at the screening visit, which we of course now are referring to risk assessment, but now the patient comes back for the comprehensive exam and most of this is populated from what was gathered during the screening form fill out. And that would include the subjective and the objective. Now maybe this patient has come back and they actually have a sleep test, which they didn't have before. So you add more components to the objective portion of the form. That wasn't there before, and now this gets added into the SOAP note. So we've covered the risk assessment and the initiation visits. I think the oral appliance delivery is pretty self-explanatory, of course, much simpler, as is the bundle of appointments that all occur during short-term follow-up and long-term follow-up as we are calibrating and monitoring the patient. I would say about the delivery appointment is that we had a lot of meetings about how much data was needed at delivery. Do we really need all this comprehensive data at the delivery appointment? And I personally prefer as much data at delivery as possible. For my own office systems, it was because I wanted to be able to remind myself as I spent time with that patient before they left about the level of their disease, what their chief complaint was. I really wanted to review all of that data briefly. And since all the SOAP notes look exactly the same, it's very easy to skim through them once you get used to your own SOAP notes. And so I could really make a final plug or push to the patient to really motivate them to stay using their device over these first critical three weeks when adherence to the device really gets us over the hump and makes for a successful or an unsuccessful long-term therapy with oral appliance therapy. So my personal feeling was have everything available at the delivery appointment like you would at any other appointment. And it will also simplify the procedures in your office because every appointment, almost every appointment where you see that patient, you're gonna always follow the same process of copying and pasting forward the same SOAP note. So again, this is what I would wanna see on delivery. I would wanna be reminded of everything subjective and objective and including, and I don't have it on this slide, but including the actual sleep data, what the diagnosis was, whether or not the patient was worse supine and give those final tips of advice for the patient that will make them successful. So just some other considerations when you look at these SOAP notes and try to imagine using them in your own practice. I believe that you are going to be customizing with all your own screeners. You may be using images, for example, CBCT, maybe you always will be taking a pan and you're gonna be customizing these SOAP notes. So please do that. If you typically use a particular kind of sleep interview, include that, include the data as you customize these. And then one last thought is one place that I think dental software tends to fall down is it cannot create a letter template very easily to send to your referring physician. And that may make you tempted to early on pay for a dental sleep medicine software. I just wanna go on record as discouraging you right now from paying for that if you are not up to speed in your dental sleep medicine practice. If you are just starting out, I would argue you want to get your systems working within your own software first. Okay, so that leaves you with this challenge of how do you create these letters that you wanna send to your physician? And I would say it isn't that difficult because you can train your team members and you might wanna do it yourself to begin with on how to copy and paste from these SOAP notes the critical components that you decide you wanna share with your physician from your SOAP notes. I personally did not send my whole SOAP note to my physician referrers and collaborators because other than want them maybe scanning that and including it into the patient's document, I didn't think it was ever anything that they were gonna look at. In the letter, I wanted to be very concise about why I was referring a patient and what I had seen that led me to that referral. Likewise, if my correspondence had to do with the delivery and my expected time of having that patient be referred back to that physician for an efficacy evaluation, I designed exactly what I wanted to copy and paste from my SOAP note. And when I was setting up my SOAP notes in my Dentrix, because that's what I used was a Dentrix program, I organized that data so that it was easy to copy and paste from my SOAP notes, just the components that I generally wanted to share with my physicians. So having said that, I know that was a little bit of a wormhole, so I apologize, but just be thinking about what you're gonna be using this data for, how you wanna use it in your clinic. Don't just take these SOAP note documents and import them into your system carte blanche. Think through your own processes first, customize them, try them out, and then continue to upgrade them as you try them out on your patient population. So I hope that helped you understand the purpose of these SOAP note documents that are being provided as a member of the AADSM benefit and thank you for your attention. ♪♪

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