How to Document a Dental Examination and Procedure Using a Dental Chart

A dental chart is a permanent record of a patient’s dental care, and completion of a dental chart is the minimum standard of care for documenting any professional dental procedure. Dental charting is the process of recording the state of health or disease of the teeth and oral cavity, and it is an integral part of the examination, diagnosis, treatment planning, and monitoring of dental cases. The dental chart provides legal documentation of the procedure performed and facilitates communication with colleagues. The scope of this paper is limited to documenting routine equine dental care (occlusal adjustment, floating, periodontal therapy, and simple extractions). Although the purpose of this paper is not to describe how to perform a dental examination, a thorough oral examination is prerequisite to completing an accurate dental chart. Additionally, to properly document any dental procedure and communicate with colleagues, practitioners must have a working knowledge of dental terminology.