- Draw an even line on the root showing the extent of resorption of the root.
- 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, 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.
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, 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 is used to record the patient's last name, first name, middle initial, and patient/sponsor Social Security Number.
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.Continue Reading