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Writing services rendered

Can you provide a sample of the format you use for services rendered for a new patient and recare patient?



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2 Answers

NEW PT HYG: HH Review: Pt had Gallbladder surgery May 2012. Pt had a Pacemaker implanted July 2006. Pt was diagnosed with HBP February 2013 and is under control. Medications: Lisinopril 12mg, HCTZ 5mg, Omeprozole 20mg, all taken once daily. Allergies: Anti-malaria medication, Penicillin, Sulfa Drugs and Latex.
Patient presents as a 46 y/o Caucasian Female with Chief Complaint of LR Sensitivity and needs a cleaning.
BP: 126/78 RAS, 98 BPM, also noted on HH Form.
FMX/BWX4/OCS(- or +): Aphthous Ulcer Left Cheek/Extra-Oral and Intra-Oral Digital PHOTOS.
Dental charting existing: see computerized charting.
Perio Charting: all findings noted: see computerized charting. Discussed Periodontal disease and it’s progression and reasons for 3-4-6mth Continued Care Intervals.
Pt has Type III Periodontal Disease and will need all 4 quadrants of S/RP. Gave “Stages of Perio disease” and “what is S/RP” and “what is Perio maintenance” pamphlets to pt.
(IF not Perio…. )
Pt is a Healthy Adult Prophy: mod biofilm, mod supra gingival calculus, mod hemo and lt stain. Ultra/hand, RCP: mint, floss.
EXAM: Decay: #2-DO, 19-O, 22-F5. Watch: #12-D Incipient Decay. Refer to Endodontist: #31 and Discussed if Endo is needed then a crown will be necessary. Refer to Oral Surgeon: #1, 16, 17 and 32 for Extractions.
Pt to come back in 1 week for a restorative treatment consult.
Periodontal treatment plan Signed, dated and scheduled.
NV: S/RP 4 Quads. Bomb Hygienist, RDH
Or
NV: 3-4-6mth Bomb Hygienist, RDH

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Holy Shitake mushroom! So thorough & that’s so important. My notes are very similar but with exam/ restorative notes after HH review instead of at the end. Electronic records make it easy with templates. I always think “if I am not here or do not see this patient again what info does the next Hyg/team member need?”

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