Prophylaxis/Preventive Services Note (Hygiene Visit)

Date of Service: [Date]

Clinician: [Name, credentials (e.g., RDH)]

Supervising Dentist: [Name, credentials] (Include only if required by state law or clinic policy; otherwise omit this line.)

Visit Type: Hygiene Visit – Preventive Services

Procedure: [Prophylaxis / Periodontal Maintenance]

Subjective

[Chief concern in patient's own words]; [Interval history since last hygiene visit including symptoms such as bleeding, sensitivity, or changes in home care]; [Medical history update including relevant conditions, medications, and allergies impacting hygiene care] (Write as a single concise paragraph. If no medical changes, state "Medical history reviewed; no changes.")

Clinical Findings

Soft Tissue: [Extraoral and intraoral findings; gingival description including color, contour, bleeding tendency, abnormalities] (State "WNL" if examined and unremarkable. If not performed, state "Not performed" with reason.)

Periodontal Status: [Assessment type performed: PSR with sextant scores / Comprehensive periodontal charting with summary findings] — [One-sentence interpretation of periodontal health and indicated follow-up] (If not performed, state "Not performed" with reason.)

Deposits: [Plaque, calculus (supra/subgingival), and stain: severity (none/light/moderate/heavy) and distribution (localized/generalized) with specific location when deposits are present] (If assessment not performed, state "Not performed" with reason.)

Assessment

Periodontal classification: [healthy / gingivitis / periodontitis / peri-implant mucositis / peri-implantitis]. Rationale for today's procedure: [Justification referencing clinical findings and history of periodontal therapy, explaining selection of prophylaxis vs periodontal maintenance]. (Include risk factors impacting prevention such as home care deficits, tobacco use, xerostomia, or diabetes only if present. Do not cite insurance benefits.)

Plan

Procedures: [Procedure completed]; [Instrumentation used: ultrasonic / hand / both]; [Polishing]; [Adjuncts if any]; [Patient tolerance and complications] (Note "tolerated well, no complications" if unremarkable.)

OHI Provided: [Topics covered and patient response or barriers identified] (Include tailored recommendations.)

Fluoride: [Type applied and post-op instructions provided] (If declined, state "Offered; patient declined." If not indicated, briefly document rationale. Omit line entirely if not applicable to visit.)

Recall: [Recommended interval] — [Clinical rationale tied to findings]; [Next planned service type if different from today] (Do not omit rationale.)

Referrals/Additional Recommendations: [Referrals or additional recommendations as indicated] (Include only if applicable; otherwise omit this line. Document any patient refusals.)

Clinician Signature: [Electronic signature, name, credentials, date/time]