When it comes to patient records it is always best to be able to confirm that a clinical oral examination was done, but writing “COE done” in a chart is NOT enough. The Clinical Oral Examination (COE) should be thoroughly documented with a systematic approach and then placed in the patient’s chart. It is important to build patient history especially in the event that a lesion or spot is discovered in the oral cavity or pharynx during a later visit. Thorough and complete documentation in a checklist manner which can be placed into a patient chart is best practice.

Besides performing a COE, some health care professionals may use adjunctive equipment or special tests to assist them with detecting abnormal areas in the mouth. Using an adjunctive device is a great way to tackle early detection but keep in mind it is the documentation process that can act as the foundation for early detection. Another advantage of thorough documentation like that of the VELscope® Vx camera system is the ability to share information with ease between referring specialists in the event that an abnormality is detected.

The goal with oral cancer screening is early detection and building patient history through comprehensive documentation can be the basis for the detection process. It can also be the basis through which a dentist can confidently deliver good news to your healthy patients with each check-up as the patient record continues to keep track of the patient’s good health. Being able to deliver a steady flow of good news chair-side after performing a COE is great for patient confidence.

Oral Cancer Screening Forms is a great online resource and can assist you with specific documents developed for the COE and provides products developed for healthcare professionals to use in the oral cancer screening process. Once the examination is complete, place it in the patient’s chart or scan it into the electronic health record and DOCUMENT! DOCUMENT! DOCUMENT!

Dr. John Roberson is  a committed professional when it comes to early detection of oral mucosal disease and oral cancer. He is an award winning Board Certified Oral & Maxillofacial Surgeon, and also has Board Certification from the National Dental Board of Anesthesiology.  He is a member of the American Association of Oral & Maxillofacial Surgeons, American College of Oral & Maxillofacial Surgeons, American Dental Association, Mississippi Dental Association, and the South Mississippi Dental Association. Learn more about his practice and dedication at www.drjohnroberson.com