Scaling & root planing, four or more teeth per quadrant note template
A complete, fill-in-the-blank D4341 note written around what insurance reviewers ask for — with the documentation checklist, the denial patterns, and an Open Dental auto-note format built in.
01 · Before you bill it
Know what the payer wants first.
The note should answer every item on the left — and read so that nothing on the right applies.
What documentation D4341 requires
Missing any of these is why the claim pends for records.- A dated six-point perio chart within ~6 months — attached, not summarized
- Four or more qualifying teeth in the quadrant listed by number, with 4 mm+ pockets and attachment loss
- Radiographs demonstrating bone loss, referenced in the note
- A named periodontal diagnosis with stage and grade
- Anesthetic details — definitive therapy, not a "deep cleaning"
- Re-evaluation and maintenance plan showing a therapy sequence
Why D4341 gets denied
The denial patterns payers actually use for this code.- Chart shows fewer than four qualifying teeth — that quadrant is D4342, and payers downcode automatically
- Full-mouth SRP in one visit without a narrative — many carriers cap at two quadrants per date of service
- No radiographic bone loss visible on the attached films (gingivitis-level findings billed as periodontitis)
- Perio chart older than six months or missing entirely
02 · The template
Copy it, chart with it.
Square brackets are the blanks — replace each one as you chart. Switch the format to turn every blank into an Open Dental auto-note prompt.
MEDICAL HISTORY: Reviewed [date]; changes: [none / list]. BP [___/___]. Pre-med: [none / regimen taken]. PERIODONTAL DIAGNOSIS: [Localized/Generalized] Stage [I-IV], Grade [A-C] periodontitis. QUADRANT TREATED: [UR/UL/LR/LL]. Qualifying teeth: [#,#,#,#] with PD 4+ mm, CAL loss, and radiographic bone loss. PERIO CHART: Six-point probing dated [date within 6 months]. BOP: [__]%. Deepest site: [_] mm at [# surface]. RADIOGRAPHS: [FMX/BWX] dated [date] demonstrating [horizontal/vertical] bone loss in the treated quadrant. CONSENT: Diagnosis, procedure, alternatives (including no treatment), and risks reviewed; patient consents. ANESTHETIC: [Agent, concentration, epi ratio] [__] mL via [IANB/PSA/infiltration]. TREATMENT: SRP of [quadrant]: ultrasonic debridement followed by hand instrumentation of root surfaces to clinical smoothness; subgingival irrigation with [agent]. TISSUE RESPONSE: [Bleeding level], controlled with [pressure]; patient tolerated well. COMPLICATIONS: [None / describe]. OHI: [Technique and interdental aids specific to the patient]. POST-OP: Written instructions given; expected sensitivity 48-72 h discussed; [analgesic] recommended. NEXT VISIT: [Remaining quadrant(s) and date]; re-evaluation in 4-6 weeks; anticipated maintenance interval [3-4 months].
03 · Common questions
Frequently asked about D4341
D4341 vs D4342?
How often can it be billed?
Is anesthetic billable separately?
More templates
Or never fill in a blank again.
Molaris listens to the visit and drafts this exact note in your wording — placeholders already filled from what was actually said. You review, you sign, it files to Open Dental.
Book a 15-minute demo →Reviewed August 2026. These templates are original Molaris reference samples showing how the scribe structures documentation. They are educational examples, not billing, coding, or legal advice; payer requirements vary by plan and state. CDT codes are maintained by the ADA.