Introduction to Charting

Sections of the Dental Chart Personal Patient Information – this may include name, address, age, employment information, telephone #, name of guardian, and medical alerts. Charting area – this is the diagrammatic representation (pictures) of the teeth Treatment Rendered – this is the written record of all treatment (and services) provided for the patient.

A dental chart is: The patient’s record of his dental condition and treatment received while he is the patient in this office or clinic. A valuable legal record. All services rendered must be recorded on it.

All entries must on the dental chart must be: Complete Correct Clear

As a valuable legal record, the patient’s chart must be protected. Charts should never be left lying around After use they should be returned to their proper places. They should be stored so as to protect them from fire, damage, or loss.

To record an examination quickly and accurately you must: Be familiar with the words the dentist is using. Know the proper symbols and abbreviations so you can use them quickly and accurately. When in DOUBT—WRITE IT OUT!!! (Don’t take chances. If you are not completely sure of the symbol, write it out completely)

Trust nothing to memory – write everything down. (Use symbols, abbreviations, or longhand..... But write it down as soon as possible) Don’t be afraid to ASK about anything that you did not hear or understand completely.

Guidelines for making charting entries Do not use a pen, either ball point or felt tip, when charting an exam. If you make a mistake you can not erase it. Use a regular black pencil for all entries, unless you are told to use a system with colored pencils. EXAM entries are made in pencil; however, all other entries are made in pen.

Learn the term the dentist will be using. Be ready to use the proper symbols to record findings. Pay attention, Listen carefully, and Don’t be afraid to ask!! Be accurate – your mistake in charting could cause the patient considerable pain and trouble.

Charting with red and blue pencils Solid blue – is used to show existing restorations. (Fillings that are in place and in good condition) Solid red – is used to show caries (decay) or other conditions that require attention. Solid blue outlined in red – used to show that a restoration is resent but must be replaced.

Classification of Cavities Class I – involves the pit and fissure caries. Class II – caries of the occlusal and proximal surfaces of a posterior tooth. Class III – caries of the proximal surfaces of an anterior tooth.

Class IV – caries of the proximal surface and incisal edge of an anterior tooth. Class V – caries on the gingival third of the facial or lingual surface of all teeth ( not pit & fissures) Class VI – abrasion of the incisal edge or occlusal surfaces of the teeth.