Transcript Recording Services Rendered

Recording Services
Rendered
Characteristics of “Services
Rendered” Entries
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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
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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
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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
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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
C&B – crown and bridge
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C.A. – Corrective Appliance
Adj. – adjustment
D.S. – denture service
D.R. – denture repair
Appl. - appliance