Scaling and Root Planing Procedure Note

Date: [Date of service]

Provider: [Provider full name, credentials (DDS / DMD / RDH)]

Location: [Clinic location]

Procedure: Scaling and Root Planing

Quadrant(s) Treated: [Full quadrant / Partial quadrant; specify which]

Tooth Numbers: [Tooth numbers treated this visit]

Primary Diagnosis: [Periodontal diagnosis]

Indication and Clinical Basis

[Periodontal diagnosis summary using standardized terminology: gingivitis vs periodontitis, localized/generalized extent, Stage/Grade per 2017 AAP classification if used by practice]

• [Date of most recent periodontal charting] (If not obtained today, note last date and reason.)
• [Radiographs reviewed: type and date] (e.g., FMX, BWX)
• [Key clinical indicators supporting SRP] (Probing depths, bleeding on probing, clinical attachment loss, furcation involvement as documented.)
• [Reference to existing treatment plan and date] (Include only if SRP is part of an established plan.)

Pre-Procedure Review

• [Medical history reviewed; no changes / Medical history reviewed with changes: brief summary]
• [Relevant allergies] (Local anesthetics, antibiotics, chlorhexidine, latex.)
• [Medications or conditions affecting bleeding or infection risk] (Anticoagulants, diabetes, immunosuppression; note management approach if relevant.)
• [Antibiotic prophylaxis: not indicated / indicated and administered: agent, dose, timing]
• [Informed consent obtained: verbal / written] (Nature of SRP, expected outcomes, alternatives, material risks discussed; questions answered; patient agreed.)
• [Site and procedure verification completed]

Anesthesia

[No local anesthetic administered / Local anesthesia administered as follows:]

• [Agent, concentration, vasoconstrictor; volume in carpules or mL; technique (infiltration / block); site(s); patient response] (One line per agent. Include only if local anesthesia used.)
• [Topical anesthetic: agent and site] (Include only if used.)

Procedure

[Global narrative: patient positioning; pre-procedural rinse agent if used; instrumentation approach (ultrasonic plus hand / hand-only). Treatment endpoint: removal of plaque and calculus with root planing to smooth, clean root surfaces.] (2–3 sentences.)

[Upper Right / UR]

• [Teeth treated]
• [Instrumentation: ultrasonic scaler / hand curettes; root planing completed]
• [Calculus distribution: light / moderate / heavy]
• [Anatomic or clinical challenges] (Deep pockets, furcations, recession, tight contacts, sensitivity.)
• [Irrigation: agent and delivery method] (Include only if used.)
• [Local antimicrobial: product and sites] (Include only if used.)
• [Bleeding level and hemostasis]
• [Patient tolerance]

[Upper Left / UL]

• [Teeth treated]
• [Instrumentation: ultrasonic scaler / hand curettes; root planing completed]
• [Calculus distribution: light / moderate / heavy]
• [Anatomic or clinical challenges]
• [Irrigation: agent and delivery method] (Include only if used.)
• [Local antimicrobial: product and sites] (Include only if used.)
• [Bleeding level and hemostasis]
• [Patient tolerance]

[Lower Right / LR]

• [Teeth treated]
• [Instrumentation: ultrasonic scaler / hand curettes; root planing completed]
• [Calculus distribution: light / moderate / heavy]
• [Anatomic or clinical challenges]
• [Irrigation: agent and delivery method] (Include only if used.)
• [Local antimicrobial: product and sites] (Include only if used.)
• [Bleeding level and hemostasis]
• [Patient tolerance]

[Lower Left / LL]

• [Teeth treated]
• [Instrumentation: ultrasonic scaler / hand curettes; root planing completed]
• [Calculus distribution: light / moderate / heavy]
• [Anatomic or clinical challenges]
• [Irrigation: agent and delivery method] (Include only if used.)
• [Local antimicrobial: product and sites] (Include only if used.)
• [Bleeding level and hemostasis]
• [Patient tolerance]

(Include only quadrant(s) treated this visit. Omit irrigation and antimicrobial lines if not used, unless clinic policy requires explicit documentation.)

Complications

[Complications: None / Description of complication(s) and management] (Always complete. If debridement incomplete, specify what remains and plan to complete.)

Post-Operative Instructions

• [Instructions delivered: verbal / written handout / both]
• [Expected sequelae reviewed: transient tenderness, minor bleeding, temporary sensitivity, possible gingival recession]
• [Home care guidance: brushing, flossing, interdental cleaning, desensitizing toothpaste if applicable]
• [Pain management: OTC analgesics / prescription with name, dose, directions]
• [Prescribed rinse: agent, schedule, duration] (Include only if prescribed.)
• [Instructions to contact office for: uncontrolled bleeding, swelling, fever, worsening pain, allergic symptoms]

Follow-Up Plan

• [Re-evaluation: date or timeframe] (Typically 4–6 weeks; assess periodontal charting, bleeding on probing, pocket depths, oral hygiene.)
• [Periodontal maintenance interval and rationale]
• [Additional planned therapy] (Remaining SRP quadrants, antimicrobials, periodontal surgery referral, restorative or occlusal therapy.)
• [Patient acceptance or deferral; barriers if any]

Supporting Documentation

• [Periodontal charting: date; full-mouth / limited]
• [Radiographs: type and date]
• [Consent form location]
• [Prescriptions written]

Provider Signature: [Provider name, credentials]

Date Signed: [Date]

(If late entry or addendum, label with date/time and reason.)