When to use this SRP template
Use it for any visit where you bill D4341 (four or more teeth in a quadrant) or D4342 (one to three teeth). SRP is a treatment for a diagnosed disease, not a deeper cleaning, and payers review it quadrant by quadrant. The note has to show why each quadrant needed root planing instead of a prophylaxis.
What a complete SRP note includes
- A stated periodontal diagnosis with stage, grade, and extent, not just "perio."
- Baseline pocket depths and bleeding for the quadrants treated, with real numbers.
- The quadrants and teeth treated, so each D4341 or D4342 line item can be verified on its own.
- Anesthetic type, technique, and amount, plus how the patient tolerated it.
- Post-op instructions and a re-evaluation date, usually 4–6 weeks out.
Example SRP note
Patient seen for SRP, 4 or more teeth per quadrant (D4341). Medical history reviewed, no changes. Diagnosis: generalized Stage III, Grade B periodontitis. Quadrants treated: upper right (Q1) and lower right (Q4), teeth #2–5 and #28–31. Pre-treatment pocket depths 5–7mm, bleeding on probing at 30% of sites or more, moderate subgingival calculus. Anesthesia: 2% lidocaine w/ 1:100,000 epi by infiltration and IANB, 2 carpules. SRP completed with an ultrasonic scaler and area-specific curettes; root surfaces smooth on explorer check. Tolerated well. Post-op instructions given. Remaining quadrants scheduled; re-evaluation in 4–6 weeks.
After SRP, document the follow-up with the periodontal re-evaluation template. Once the patient is stable, switch to the periodontal maintenance template.