Recording Services Rendered

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Recording Services Rendered
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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.

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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.

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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 patients mouth.
• F.T., Fl-, Flo fluoride treatment

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• 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.

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• 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

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• 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
• CB crown and bridge

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