Periodontal Charting and Documentation

Progress Notes

Periodontal Forms

Electronic Perio Chart

Pocket Depths
! ! !

6 sites per tooth 3 mm or less in blue 4 mm or greater in red

Bleeding Documentation
Bleeding on probing - circle number ! Describe - delayed bleeding on probing - mild, moderate, heavy bleeding
!

Bleeding Documentation

moderate generalized bleeding on probing

heavy bleeding posterior molars

6 sites per tooth ! CEJ to base of pocket

!

Attachment Loss

Attachment Loss Documentation

6 sites per tooth

Recession Documentation

Furcation Documentation

Furcation Documentation
1 = slight depression 2 = roof and a catch 3 = through and through 4 = furca is supragingival
F3 F3 Premolar mand molar F3

max molar

Furcation Documentation

F3

What Classification?

Mobility

Mobility Documentation
Mobility N = normal + = slight movement 1 = up to 1mm 2 = up to 2 mm 3 = greater than 2mm

Mobility Documentation

Gingival Description

Gingival Contours

Gingival Descriptions
Healthy 3 Cs Color - coral pink Contour - knife like - embrasure filled Consistency - firm and stippled

Color
- red - erythema

Gingival Descriptions

Contour
- blunted, cratered - rolled

Consistency - edema Location

- smooth and shiny - fibrotic - generalized or localized

SOAP DOCUMENTATION
! S - SUBJECTIVE ! O - OBJECTIVE ! A - ASSESSMENT ! P - PLAN AND PROCEDURES

SUBJECTIVE
Reason patient is present for treatment - Recall or Perio Maintenance or Root Planing Statements from the patient - Patient self-care Changes in Medical History - Pre-Medication dosage taken Chief complaint or concern Patient Identification Verification PIV

OBJECTIVE
! Clinical observations and conditions ! Blood Pressure, pulse, ASA classification ! Summary and/or specifics from the periodontal
assessment and the Head/Neck examination

! Areas of clinical concern ! Comments on clinical concerns and the patients selfcare status

ASSESSMENT
! PERIODONTAL CLASSIFICATION ! CARIES STATUS - Active, At Risk, Controlled ! DEPOSIT CLASSIFICATION - calculus ! ETIOLOGY - - Plaque, Med systemic, Smoking,
Self-Care, Patient Compliance dentition

! PROGNOSIS - for a specific tooth or the

PROCEDURES AND PLAN

! Specific procedures performed at the appointment - Root
Planing with anesthesia, Recall, Radiographs, Fluoride applications, Consults with specialists, Documentation of Self-Care discussion with patient goals, Dispensing of Rx samples with directions 3MRC, Reevaluation, Operative

! Plan for the next appointment - return to Clinic for RP,