Recording Services Rendered

Characteristics of “Services Rendered” Entries All “services rendered” entries must be made in Ink (blue or black). Information must be: Correct – Complete – Clear. Your handwriting must be neat and clear so that someone else can read it. Entries must be made Promptly. Usually this is done before the patient leaves at the end of the visit. To save time and space, abbreviations are used to describe the commonly preformed services.

Parts of the “Service Rendered” Entry The Date – In the U.S. it is stated by Month, Day, Year. Use numbers! The Tooth – If something is done for one specific tooth the number of that tooth is entered here. If something is done for the whole mouth, such as an examination or a prophy, this space is left blank. The Service Rendered - this is a detailed description of each patient visit. Listed here are all parts of the service rendered including materials and medicaments used.

Common Abbrevaiations Ex – examination Prophy or Pro – prophylaxis is the professional cleaning and polishing of the teeth. S.M. – study models are a three-dimensional record of the patient’s mouth. F.T., Fl-, Flo – fluoride treatment

X-ray – radiographs C.M.X. – complete mouth x-rays or full mouth series containing14, 16, or 18 x-rays. B.W. x-ray – bite wing (includes the crowns of max. & mand. teeth) P.A. x-ray – periapical includes the root & crown of a specific tooth Pedo x-ray – smaller film used for children. Occ x-ray – Occlusal film is larger and so named because the patient bites on the film.

Amal – amalgam commonly referred to as a silver filling Comp – composite resin is the tooth colored filling material C.B. – cement base placed under a restoration Anes. – anesthesia is the drug that causes a loss of pain but not a lose of all sensation

S.T. – sedative treatment T.T. – temporary treatment Ext – extraction Sut. – sutures (always write the number of sutures placed) P.O.T. – post operative treatment Crn - crown C&B – crown and bridge

C.A. – Corrective Appliance Adj. – adjustment D.S. – denture service D.R. – denture repair Appl. - appliance