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