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.
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. 🙂
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.
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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