Charting Notes
Every person in the office is expected to be familiar with and correctly use the procedure codes outlined in the CDT 4 booklet kept at the front desk.
These AutoCorrect codes, which should be installed in MS Word on each computer in the office, should provide a uniform, modifiable, coherent and very easy way to do 90% of our charting. While deviations from the use of these standard charting notes may at times be necessary, any individual, customized charting must contain the same information as these standard notes and be clear, complete, unambiguous, and lucid.
Abbreviations should not be used in clinical charting. If it is a frequently used series of words, it should be added to the MS Word Autocorrect codes listed below.
When “signing” the charting, the name of the person who actually writes and posts the notes comes first, followed by the name of the other people who participated in the patient’s care. For example, if Percy and Jason treated a patient and Percy did the charting, her name would appear first at the end of the charting followed by Jason’s name. If Julie, Terry and Bruce treated a patient but Terry did the charting, Terry’s name would come first followed by Julie and Bruce’s names.
All abbreviations in autocorrect should be entered in lower case letters.
MS Word AutoCorrect Definitions:
lp:
Linda Piccinini, RDA 42939
tm:
Teri Martinez, RDA 54282
jb:
Julie Brandt, RDA 12294
bas:
Bruce Stephenson, DDS 27075
jcc:
Jason C. Chen, DDS 50227
pu:
Percelita R. Urbi, RDA 30237
cdh:
Carol Deacon-Hake, RDH 7673
ncr:
Nadine Cross-Ratto, RDH 15424
mny:
Mark N. Yanga, RDA 76811
rlb:
Ray Berolotti, DDS, PhD
Dra:
Deelaine Alvarez, DA
je
Jenny Escobedo, DA
ma
Marina Almaraz
Practice Administrator
ts:
Tamara Synigal
Practice Manager
bdds:
Binh Lam, DDS 59595
bastm
Bruce Stephenson, DDS 27075
Teri Martinez, RDA 54282
Tmbas:
Teri Martinez, RDA 54282
Bruce Stephenson, DDS 27075
ecbe:
Initial placement; Endodontics completed by endodontist
notooth:
Large restoration with extensive recurrent caries; inadequate amount of tooth structure remaining to provide sufficient longevity for anything other than full cuspal coverage with laboratory processed restoration.
nip:
Not initial placement; age of pre-existing crown is indeterminate but appears to be approximately 12 years old; recurrent caries present on the (indicate surface)
foc:
Fractured off (indicate which cusp or cusps) cusp(s)
nipb:
Not initial placement, replaces (??) year old bridge with recurrent caries (indicate tooth and surface)
ipb:
Initial placement; tooth was extracted (indicated number of years ago) and has never been replaced.
ipc: (include tooth or teeth number(s))
Tooth # XX: Indirect pulp cap: gluma, Vitrebond liner over deep areas of discolored dentin overlying pulp; pt aware endo may be necessary in future but wishes to attempt this option.
maximpconsent:
Again discussed risks, benefits and alternative of implants with patient. Pt is aware of poss bruising, swelling, infection, nerve or sinus damage or infection, loss of implant(s), and possible additional surgery by me or by another surgeon. Pt wished to proceed with implants.
mandimpconsent:
Again discussed risks, benefits and alternative of implants with patient. Pt is aware of poss bruising, swelling, infection, nerve damage or infection, loss of implant(s), and possible additional surgery by me or by another surgeon. Pt wished to proceed with implants.
dwpr:
Doctor discussed with patient the risks, alternatives and benefits of proposed treatment. Risks of local anesthesia also discussed including soreness, bruising, swelling, and prolonged or even permanent paresthesia or anesthesia.
I discussed with patient the cost of the proposed treatment and the possible payment options. (insert name of staff person followed by name of doctor)
barf
Benefits, alternatives, risks and fees discussed with patient.
invconsent
Invisalign risks, benefits and alternatives discussed with pt including option of no tx or conventional fixed orthodontics and / or referral to orthodontist. Also discussed need for 22 hour / day aligner wear, attachments, IPR, and necessity for perpetual retention to prevent relapse. Explained that no refunds are possible once tx is started even if pt abandons tx and that outcomes are variable. Tx time estimated as 6 to 12 months but longer tx time and possible case refinements possible. Pt wishes to proceed with tx.
Bruce Stephenson, DDS Teri Martinez, RDA
Cpser2:
Prep and caries removal: SE Bond primer x 20 seconds; SE bond bonding agent placed and light cured for 10 seconds; Estelite Shade A2 placed, pulse light cured than final light cure for 40 seconds, finished and polished.
cerecr
Prep and plain cord retraction; Cerec impressions; designed, milled; adjusted and polished restoration; etched restoration x 1 min; preparation prepared with etch for 20 seconds, gluma for 20 seconds, Photobond; luted with panavia; block used: XX
Cerecr2
Prep and plain cord retraction: Cerec impressions; designed, milled; adjusted and polishedrestoration; etched restoration x 1 min; applied silane; bonded with Multilink Automix; translucent; block used; xx
Cerecr3
Prep and plain cord retraction; Cerec impressions; designed, milled; adjusted and polished restoration; etched restoration x 1 min; applied interface silane; bonded with Surpass/Anchor cement; translucent; block used: xx
Cerecr4
Prep and plain cord retraction; Cerec impressions; designed, milled; adjusted and polished restoration; etched restoration x 1 min; applied Monobond plus; cemented with Relyx luting Cement; block used: xx
cpr:
Prep and caries removal; etch x 20 seconds; gluma x 20 seconds; Photobond; Estelite A2 placed, pulse light cured than final light cure for 40 seconds, finished and polished.
cpser:
Prep and caries removal; SE Bond primer x 20 seconds; SE Bond bonding agent placed and light cured for 10 seconds; Estelite Shade A2 placed, pulse light cured than final light cure for 40 seconds, finished and polished.
cpfr:
Prep and caries removal; etch x 20 seconds; gluma x 20 seconds; Photobond; Starflow placed along gingival margins and light cured for 20 seconds; Estelite ShadeA2 placed, pulse light cured than final light cure for 40 seconds, finished and polished.
pvr:
Initial placement; porcelain laminates were done as more conservative option in lieu of castings to replace fractured composites with recurrent caries on the following teeth: (indicate which teeth had extensive pre-existing restorations)
sbr: (sandblaster restoration)
No local; air abrasion preparation; etch with 35% phosphoric acid for 30 seconds; Photobond; Starflow.
pbmr:
Pre-op blue mouse double-bite; Caries removal and preparation; plain cord retraction with Astrigident; blue-mouse and silicone wash in a double-bite tray; Luxatemp temp cemented with Tempbond Clear; shade: see lab slip
fgcr:
Pre-op blue mouse double-bite; Caries removal and preparation; plain cord retraction with Astrigident; blue-mouse and silicone wash in a double-bite tray; Luxatemp temp cemented with TempBond Clear;
Hygiene and Periodontal Procedures
rp:
Scaling and root planing
pm1:
Active periodontal treatments completed (month, year)
pm2:
Patients periodontal status has been satisfactorily maintained with periodontal maintenance therapy; there has been no increase in pocket depth, bleeding on probing or attachment loss.
Pct1:
Case Type I: Gingivitis; no radiographic evidence of bone loss; no clinical attachment loss
Pct2:
Case Type II: Early Periodontitis; Pocket depths or attachment loss of 3 to 4 mm
Pct3:
Case Type III: Moderate Periodontitis; Pocket depths or attachment loss of 4 to 6 mm
Bleeding upon probing; Grade I and/or Grade II furcation invasion areas; radiographic bone loss
Pct4:
Case Type IV: Advanced Periodontitis; bleeding upon probing; pocket depths or attachment loss over 6 mm; Grade II, Grade III furcation involvement; mobility of Class II or Class III; radiographic bone loss
Rpn3:
Type III periodontal disease; generalized 4-6 mm bleeding pockets exhibiting attachment loss and subgingival calculus; radiographic crestal bone loss; see attached detailed periodontal charting and radiographs.
Rpn4:
Type IV periodontal disease; generalized 5-7 mm bleeding pockets exhibiting attachment loss and subgingival calculus; radiographic crestal bone loss; see attached detailed periodontal charting and radiographs.
Rpn1-3:
Type III periodontal disease; localized 4-6 mm bleeding pockets exhibiting attachment loss and subgingival calculus; radiographic crestal bone loss; see attached detailed periodontal charting.
pofv:
Painted on fluoride varnish.
kidr:
Scaled, polished, flossed, painted on fluoirde varnish. Demo tooth brushing, floss and stressed the need for nightly fluoride rinses.
Fvr:
Fluoride varnish indicated by CAMBRA protocols due to xerostomia and increased caries risk
Arest-d
Discussed risks, benefits, and alternatives with pt for use of Arestin; also informed pt of charge for use and that it is usually not covered by dental insurance. Pt declined Arestin treatment.
Arest-a
Discussed risks, benefits, and alternatives with pt for use of Arestin; also informed pt of charge for use and that it is usually not covered by dental insurance. Pt accepted Arestin treatment.
cra:
Discussed pt’s increase caries risk and recommended fluoride varnish application but pt declined recommendation.
Bgr2
30/30/40 mix of Dynagraft/ Accel / Mineross particles into site; overlay.
bhr:
Initial placement: tooth # extracted (date)
1 carp of 4 % cit forte w. epi 1:200,000
1 carp of 4 % septocaine w. epi 1:200,000
Used surgical guide with ____ sleeves. Used (insert size of drills) drills from Anatomage with irrigation. RPM at 150 and Biohorizon internal implant(insert what kind of implant) mm torqued down to 35 N. healing abutment placed. Prescription of amoxicillin 500 mg TID for 5 days and peridex dispensed to use BID. One week post-op made.
impr
Four carpules of citanest with Forte 4%; Gave 2 gm amoxicillin PO at beginning of appt; buc infil with citanest with Forte 4%
Peri-oral and intra-oral prep with Peridex; guided surgery with template and sequentially enlarged osteotomy to place implants:
Good initial stability; pt tolerated procedure very well; no sutures; post op pano; post op instructions given. RX for norco-10; amoxicillin and disp peridex to use bid starting tomorrow. Post op appt made. Pt tolerated the procedure well.
Bruce Stephenson, DDS
Teri Martinez, RDA
la1:
One carpule of citanest 4%
la2:
Two carpules of Citanest Forte 4%
la3:
Three carpules of Citanest Forte 4%
la4:
Four carpules of Citanest Forte 4%
las:
One carpule of Septocaine 4% epi , 1:200,000
labas:
One-quarter carpule plain citanest 4% and one carpule Septacaine 4% with 1:200k epi
Lido:
One carpule of Lidocaine HCL 2% with 1:100k epinephrine
err:
Emergency Visit:
Subjective:
Objective:
Assessment:
Plan:
Wnl:
within normal limits
nka:
No known allergies to any medications
pco:
Patient complaining of
Zoomr
Risks, benefits again reviewed with patient. Pre-treatment photos and shade recorded. Alginate impressions taken for upper and lower arches for the fabrication of take home whitening trays and maintenance. Applied vitamin E oil to lips; face bib and protective light guide placed on pt to expose all smile line (from bicuspid to bicuspid, upper and lower). Patient given protective Zoom eyewear. Isolated all soft tissues with gauze and cotton rolls(included in patient kit). Applied Liquidam to exposed gingival tissue and light cured for 10 seconds. Applied Zoom whitening gel to both arches from bicuspid to bicuspid 1-2mm thick on Facial surfaces as per Zoom instructions. Aligned light to light guide and occlusal plane. Illuminated teeth with light for 15 minutes per session, totaling 3 sessions (45mins total) as per Zoom instructions. Whitening gel and all barrier materials removed when procedure is complete. Fluoride is applied (discus dental) Post treatment photos and shade recorded. Delivered bleaching splints. Reviewed at-home bleaching instructions and post-op Zoom with patient.