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Back Charting Symbols (Box 1) | Up Dental Technican, Volume 2 - Dentist training manual for military dentists | Next 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 dentists 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 patients 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 patients 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.
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