SRP+Treatment+Note+Example

Pt arrived on time to continue OD and begin phase 1 perio treatment (SRP UL/LL). NCMH. Pt is currently taking Lisinopril 25mg BID for HTN. BP: 132/72

EOE: NSF, cancer screening revealed NSF

PI: 100, Mobility: Class 1 #2 and 15. Furcation involvement Grade 3 (#15DL), Grade 2 (#15ML ), Grade 1 (#2B, #15B). Mucosa normal with average biotype. Rolled margins with edematous/spongy consistency. Tissue is generally pink in color. Local areas of erythematous tissue in lower arch due to excessive calculus build-up. Mild BUP with moderate bleeding upon instrumentation. Pt has generalized moderate calculus deposits. Probing depths are generally between 3-5mm with a 6mm probing depth on mesial of #22. Clinical Perio Evaluation: Generalized Chronic Moderate Arrested periodontitis w/ chronic local advanced in the area of 23-26.

Pt was anesthetized using LI of #15, MSA and ASA and GP nerve block with 2.7cc of 2% Lidocaine w/1:100k epi. SRP performed on UL quadrant as well as #21 and #22. Due to number of teeth present in lower arch, pt was charged only for code D4341 for the UL quadrant. #21 and 22 were included in that charg. Pt gave verbal consent for that treatment. The same will be charged for the UR quadrant.

NV: Pt will be seen 9-21-12 at 2pm for UR SRP (+ #27 and #29)