How to Chart Dental Exams With Charting Techniques

Dental charting is important for noting the full dental history of a patient. Documentation of all teeth and gums is imperative in order to detect and dental diseases or infections. The permanent record includes radiograph images of the teeth and soft tissue. Clinical exams at the dentist office are documented by the dentist and dental hygienists. One of the most effective ways to chart during dental exams is through a two-person charting system. One person does the dental exam while the other records the findings.

Instructions

• 1

  Evaluate the patient's gum and teeth for any calculus, or tartar. Any calculus that is visible is graded on the dental chart as 1 through 3. A 3 indicates heavy calculus are visible on the exam.

• 2

  Examine the patient for any missing teeth. Document any missing teeth on the dental chart by circling the appropriate tooth image on the chart.

• 3

  Document any tooth abnormalities in shorthand abbreviations. Tooth surfaces are abbreviated as the following, M for mesial, D for distal, L for lingual, O for occlusal, I for incisal, F for facial and B for buccal.

• 4

  Document any other abnormalities. Use abbreviated terms in order to effectively chart. Shorthand allows for faster charting.