Are you lost trying to describe oral lesions? Do you know exactly what to write?
According to the best practices and textbooks, there are the 8 categories of descriptions that you should always fill in. If your patient had the following lesion, how would you chart it?
After you complete the 8-step oral lesion charting, then you can start formulating a differential diagnosis. You could also get the doctor or specialist’s attention. Remember that documentation can save your patient’s life!
Congratulations for taking the time to understand how to provide better services to your patients! Would you like the 1-page summary you can put by your dental chair? You can print it and keep it nearby until you can memorize the 8-steps. Soon, you will be a pro!
The 8-step oral lesion description includes the following:
- Distribution and definition
- History (patient’s record)
Practice case study
Here is an example of how you could chart the following oral lesion.
- Location: On the patient’s right side of the lower labial mucosa, about 1 cm right to the labial frenum, 2 cm above the vestibule.
- Distribution and definition: localized, single, and well-defined with regular borders.
- Size: 5mm in diameter.
- Shape: Round. Vescicle (elevated lesion), with sessile based.
- Color: White inside with red borders.
- Consistency: soft, similar to the surrounding tissue.
- Texture: Smooth.