Cleaning+Treatment+Note


 * TREATMENT NOTES **
 * Treatment Notes Need to Include a Statement for Each of the Following Categories.**


 * Medical History:** i.e. changes to medications, hospitalizations, premedication


 * Chief Complaint:** i.e. patient complains of broken tooth upper right.


 * I/EOE:** detailed description including size, shape, color, and location of lesions

Color: pink, red, cyanotic Architecture: knife edged, rolled, rounded, blunted, bulbous, cratered, clefted Consistency: firm, fibrotic, spongy, soft Texture: stippled, smooth, shiny
 * Periodontal Tissue Description:** i.e. inflamed or healthy, generalized or localized


 * Probe Depths/Attached Gingiva/Mucogingival Defects/Furcation Involvement/Mobility:** i.e. generally 2-3mm with localized 5-6mm in upper right quadrant, localized or generalized BOP; generalized 1-3mm recession with inadequate attached keratinized tissue #28 facial. Class I furcation #3-D, B, Class II furcation #31-B, Class II mobility #8

Incipient/Early: <20% radiographic bone loss and/or 1-2mm attachment loss Moderate: up to 20-40% radiographic bone loss and/or 3-4mm attachment loss Advanced: >40% radiographic bone loss and/or > or equal to 5mm attachment loss i.e. generalized moderate chronic adult periodontitis with localized advanced chronic periodontitis in mandibular anterior #23-26.
 * Periodontal Diagnosis:** generalized (> 30% of sites) or localized (< 30% of sites); gingivitis: mild, moderate, or severe or periodontitis: arrested, chronic adult, or aggressive


 * Plaque and Calculus:** plaque index; generalized or localized; light, moderate, or heavy subgingival or supragingival; i.e. PI: 65% Patient has generalized light plaque with localized heavy plaque on the buccal of the maxillary second molars. Light generalized supragingival calculus with localized moderate subgingival calculus #2-#4.


 * OH/OHI:** excellent, good, fair, poor i.e. patient’s OH is fair. Patient reports brushing in the morning only and does not floss. Reviewed proper brushing technique and stressed importance of twice daily. Also encouraged daily interproximal cleaning and reviewed proper flossing and proxabrush technique.


 * Therapy and Procedures Performed:** i.e. full mouth debridement using piezo and hand scale, polished, flossed.


 * Dental findings:** generalized moderate occlusal wear, caries #3-O, #5-B


 * NV:** must include a recall interval i.e. Q6 adult prophy or Q3 or Q4 perio maintenance