Professional Documents
Culture Documents
Progress Notes
Periodontal Forms
Pocket Depths
! ! !
Bleeding Documentation
Bleeding on probing - circle number ! Describe - delayed bleeding on probing - mild, moderate, heavy bleeding
!
Bleeding Documentation
Attachment Loss
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
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