Free Scaling and Root Planing (SRP) Note Template, D4341/D4342

How to write a scaling and root planing note

An SRP note has to support the medical necessity of the procedure: a periodontitis diagnosis, pocket depths, radiographic bone loss, and the quadrants and teeth treated. It also records anesthesia, consent, and the re-evaluation plan. This template is built around D4341 (four or more teeth per quadrant) and D4342 (one to three teeth per quadrant).

Pick the procedure code, then confirm medical history, premedication, and consent.
Set the diagnosis using stage and grade, and choose whether it is localized or generalized.
Select the quadrants treated today, and the teeth when you're billing D4342. Record pre-treatment pocket depths, bleeding, subgingival calculus, and radiographic bone loss.
Document anesthesia: agent, technique, and number of carpules. Then the instruments used, the endpoint, and any adjuncts such as locally delivered antimicrobials (D4381) with their sites.
Add tolerance, post-op instructions, home care, and the plan for remaining quadrants and re-evaluation. Copy the note into your PMS.

Example scaling and root planing note

A fictional patient, filled in with this template and copied as-is.

Maria Lopez was seen by Alex Rivera, RDH on October 14, 2026 for SRP, 4 or more teeth per quadrant (D4341). Medical history reviewed, no changes. Antibiotic premedication not indicated. Informed consent obtained, risks, benefits, and alternatives reviewed.

Diagnosis: Generalized stage III, grade B periodontitis.

Quadrants treated: Upper right (Q1) and lower right (Q4). Pre-treatment pocket depths 5–7mm, bleeding on probing generalized, 30% of sites or more, moderate subgingival calculus confirmed on exploration. Radiographs show horizontal bone loss. No mobility noted.

Anesthesia: 2% lidocaine w/ 1:100,000 epi by inferior alveolar nerve block and infiltration, 3 carpules.

Scaling and root planing completed using ultrasonic scaler and area-specific curettes. Endpoint: Root surfaces smooth on explorer check. No adjuncts used.

Tolerated procedure well, no adverse reaction. Post-op instructions given: Expect cold sensitivity for a few days, avoid chewing until anesthesia wears off, and OTC analgesic as needed. Home care reviewed: Interdental brushes and electric toothbrush recommended.

Plan: Remaining quadrants scheduled. Re-evaluation in 4–6 weeks to re-probe and assess tissue response. Next phase: Periodontal maintenance if response is favorable.

What a complete note covers

Code and scope: D4341 or D4342 per quadrant, with tooth numbers for D4342.
Medical history, premedication, and informed consent.
Diagnosis with extent, stage, and grade.
Baseline findings: pocket depths, bleeding, subgingival calculus, radiographic bone loss, mobility and furcations.
Anesthesia: agent and concentration, vasoconstrictor, technique, and amount.
Instrumentation and endpoint, plus adjuncts and the sites they were placed.
Post-op instructions, home care, and the re-evaluation interval.

Common mistakes

No pocket depths or radiographs referenced. Payers commonly ask for a recent periodontal charting and radiographs showing bone loss.
D4342 without tooth numbers. The note should list which one to three teeth were treated in each quadrant.
Anesthetic without amounts. Record the agent, vasoconstrictor, and number of carpules.
No consent documented. Note that risks, benefits, and alternatives were discussed, or that a form was signed.
No re-evaluation plan. SRP should end with a scheduled re-evaluation to re-probe and decide between maintenance and referral.

Questions

What is the difference between D4341 and D4342?

D4341 is SRP of four or more teeth in a quadrant; D4342 is one to three teeth in a quadrant. You can use different codes for different quadrants in the same visit.

When is the re-evaluation scheduled?

Typically 4–8 weeks after the last SRP visit, to give the tissue time to respond. The template offers 4–6 and 6–8 weeks.

How do I document locally delivered antimicrobials?

Choose the adjunct and type the sites, for example "#3 DB, #14 MB". D4381 is reported per tooth, so the sites matter.

Related templates and guides

Example notes use fictional patients. Coding notes are general guidance; confirm against the current CDT manual and the patient's plan.

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.