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Perio Charting Technicality

So – This is always a hot subject regarding frequency and recording it, etc.
MY question is (I understand standard of care, Perio Chart 1xyear ages 18+). Must it be recorded in the program designated for perio charting OR is it still legal and acceptable to note that probing was 1-3mm, slight bleeding and name specific areas that differ. This would be an example note:

Probing: 1-3mm slight bleeding; 5mm 28D w/ bleeding, 4mm 13M w/ bleeding

My office will ‘spot check’ @ appt w/o Dr. Exam (full probe just no recording) – and I don’t believe they re-do the entire perio charting on exam day, but rather record in their notes.

Curious if this is acceptable as it can get confusing/take time to pull up old perio #’s and change them/possibly make an error.



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3 Answers

I make clinical notes about areas of perio concern but also do a full Charting 1x/year, more if necessary. It is always best to have more documentation, rather than not enough. 🙂

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I Perio chart every single patient at every single visit. I always have an assistant……whichever assistant is free at the beginning of my appts. The computer program is set to bring forward previous Perio charting so that I can evaluate the attachment levels and place on a graph through the dental charting so I can visually see if recession is increasing. Perio therapy pts must have Perio charting at every visit. Adult Prophy since I have someone entering the numbers usually are every appt unless there is an issue with help……but if do it myself I do probe everywhere and refer back to previous and change any numbers that have changed that day.

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Not sure of the legality of not recording the perio charting in the computer every year. In my office I’ll spot probe during the visits I don’t take radiographs and will chart in the notes “spot probed” with gen or loc findings. Once a year I will probe with the recordings in the computer. I have an assitant help with typing in the numbers so that seems to help speed up the process. I believe standard of care includes accurate recordings in the computer once a year so maybe having someone help you type in the numbers will make it faster.

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