Chart Codes

At the end of each visit, you will record the treatment notes in the patient’s chart. The patient’s chart is a legal medical record. You must record every discussion between patient (or parent) and doctor. You will also document what was done during the appointment. Refrain from using slang or unprofessional verbiage. The Training Manual has a list of the chart codes and verbiage to be used when documenting in a patient’s chart. Study these as the following:

BT- Bite turbos

WT- wire tie

PC- power chain

U/L- upper and lower

CL- Class (when charting about elastics)

SS- Stainless Steel

Cuniti- Copper nickel titanium

PT- patient

NV or NA- Next visit or Nex appt

AUX- Auxilaries

TLC- Used as a way to notify front desk, assistants or dr's that the patient has special needs or has a hard time with appointments and may need more TLC (tender love and care)

IB- Initial bonding

Adj- Adjustment or adjust