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Page Title: Charting Symbols (Box 2)
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Charting Symbols (Box 1)
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Dental Technican, Volume 2 - Dentist training manual for military dentists
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INSTRUCTIONS FOR COMPLETING THE BACK OF THE EZ603

RESORPTION OF ROOT.—Draw  an  even  line on the root showing the extent of resorption of the root. P E R I O D O N T I T I S    A N D    A L V E O L A R RESORPTION. —Indicate   the   extent   of   gingival recession  by  drawing  a  continuous  line  across  the roots to approximate the extent of involvement. Draw another continuous line at the proper level across the roots  of  the  teeth  to  indicate  the  extent  of  alveolar resorption.  Base  this  finding  on  the  dentist’s  clinical and  radiographic  findings. Box 2 Box  2,  Missing  Teeth  at  Time  Of  Accession  and Treatments Completed After Accession replaces box 8 (old box 15) on the SF 603/603A and functions in the same way with the following exceptions: The  information  is  cumulative  on  this  form throughout  the  patient’s  military  career. Missing teeth from the accession exam are also included  in  this  box.  By  including  this information, the SF 88, box 18 (old box 44) can be completed by looking at boxes 1 and 2 of the Current Status Form. All  extractions,  restorations  and  root  canal treatment completed during the patient’s service career are entered using the symbols mentioned previously in this  chapter  under  designations,  abbreviations,  and charting. When indicating fixed partial dentures, ignore the spaces on the form in between the teeth and draw the prosthesis on each tooth as usual. Only use black ink to make entries in box 2. Charting Symbols (Box 2) Use  the  same  instructions  and  symbols  from  the Forensic  Examination  section  for  charting  Missing teeth at Time of Accession and Treatments Completed after  Accession  (Box  2).  When  charting  existing restorations,   draw   the   restoration   and   show   the approximate size, location, and shape in the diagram of the   tooth. Identify   missing   teeth   and   restorative materials  as  previously  shown  in  the  Forensic Examination  section  (Charting/Markings).  Note:  No remarks  are  made  on  the  Current  Status  form  to indicate materials used. Box 3 Box  3,  Medical  Alert,  is  readily  seen  by  all clinicians when opening the record. If a medical alert exists,  the  word  "ALERT"  is  written  or  stamped  in large  red  letters  with  a  brief  explanation  following (i.e.,  ALLERGIC  TO  PENICILLIN).  The  use  of  red ink stamps is encouraged. Box 4 Box 4 is used to record the patient's last name, first name,   middle   initial,   and   patient/sponsor   Social Security Number. DENTAL  EXAM  FORM The Dental Examination form (EZ603) (fig. 2-22), is a new form that replaces part of the front of the old SF  603  and  all  of  the  various  SOAP  (subjective, objective, assessment, and plan) formats. It is intended to be used on the initial, subsequent periodic, annual, recall, SF 88, and separation exams. It is not intended for emergency or specialty consult exams. All entries are  made  in  black  ink  except  as  noted.  During  the dental exam, the examining dentist may direct you to fill  out  the  EZ603  and  associated  boxes  on  the  form with information. The front page of the Dental Exam Form  contains  the  "S,"  "O,"  "A,"  and  "P"  sections  of the exam that are briefly discussed next. Subjective  Section  (S:)—This  section  of  the form  is  used  to  fill  out  the  reason  for  the examination and the patient's chief complaint. Objective  Section  (O:)—This  section  is generally  meant  to  record  findings  and  not  a diagnosis. The  major  exception  is  the  caries section where the findings and diagnosis are one and the same. Assessment   Section   (A:)—This   section   is generally  used  by  the  examiner  to  make  a diagnosis. Plan  Section  (P:)—This  section  is  the "Treatment Plan" for the patient. The EZ603 is a new trial form and may be changed in  the  future.  Instructions  for  the  completion  of  the EZ603  can  be  found  in  MANMED,  chapter  6,  or current BUMED instructions. 2-21

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