4Y051P CDCs Volume 1 Unit 3
Explain when an AF Form 570 is removed from the patient's record.
If PH projects a specific time frame for the contagious stage, the dental service removes the AF Form 570 from the patient's record on that date. Otherwise, when follow-up test results indicate the patient is no longer contagious, the PH notifies the dental service and the form is destroyed at that time.
When is completion of item 5 optional?
If the treatment is to be on an emergency basis only
Under what conditions are active duty members who are separating from the military not eligible for VA dental treatment? What action and documentation is required?
If they are provided a complete dental examination (type 2) and all appropriate dental services and treatment are completed within 90 days prior to discharge or release. Screen dental records before sending to MPF for separations or out-processing. If criteria is met enter as the last entry on the SF 603 or 603A: "separation, examination and treatment completed within 90 days of separation or release." Date and sign the entry.
List the codes and the associated tobacco type for documenting tobacco use.
0- No tobacco use, 1- smokes tobacco products only, 2- Uses smokeless tobacco products only, 3- Uses both smoking and smokeless tobacco
Pulpal or periapical pathology requiring treatment.
Class 3
Dental examination required.
Class 4
Dental readiness classification unknown.
Class 4
What caries code would be documented for a patient with a history of one carious lesion in the past 3 years, and at what risk level would this patient be?
Code 2- moderate risk
What PSR code would be documented when the colored area of the probe remains completely visible in the deepest probing depth in the sextant and subgingival calculus and/or defected margins are detected?
Code 2.
What patient identification entries are made in pencil and why?
Component/status, rank/grade, and organization. All three of these may change from time to time; thus, penciled entries will make it easier to change the entries as appropriate
List the items included in section I of the SF 603.
(1) Item 1. Purpose of Examination. (2) Item 2. Type of Exam. (3) Item 3. Dental Classification. (4) Item 4. Missing Teeth, Existing Restorations, and Prosthetic Appliances. (5) Item 5. Diseases and Abnormalities. (6) Item 6. Indicate X-rays Used in This Examination. (7) Patient's Identification.
What treatment is needed for a PSR code 4?
A comprehensive full mouth periodontal examination and charting by a dental provider is necessary to determine an appropriate treatment plan
Who must notify patients of the histopathologic diagnosis?
A dentist.
Briefly explain what is required for military personnel scheduled for remote or isolated duty assignments to receive a dental clearance.
A type 1 or 2 examination, or an evaluation of the examinee's dental health record by a dentist. If the member had a type 1 or 2 examination in the last 3 months, clearance can be accomplished by evaluating the dental health record or examination
What form is used to notify the dental service of patients diagnosed with communicable diseases that place dental personnel at high risk?
AF Form 570, Notification of Patient's Medical Status
The patient is suffering from an acute and severe periapical abscess of the maxillary right first molar. Treatment consists of removing the tooth with one carpule of 2 percent xylocaine (1:50,000 epinephrine) for anesthesia.
Abs per acute severe #8 ext anes 2 percent xylo 1:50:00 epi 1.8ml
When are AFDRAP updates made?
After completing a periodic dental examination. When the dentist changes the patient's dental readiness classification. When the last entry in the SF 603 or 603A indicates a class change, a technician may change the patient's class, and to correct an error
What does the information recorded in item 5 of the SF 603 indicate? What minimum type of examination is required to chart item 5?
Any oral diseases or abnormalities detected during the initial examination. Type 2.
For what purpose is a type 4 examination most frequently used and what does this examination include?
As a dental survey and to determine the need for oral hygiene instructions for individuals. It consists of a mouth-mirror and explorer, or tongue depressor examination with whatever illumination is available.
How are inflammations recorded?
As acute or chronic, and as mild, moderate, or severe
What information is recorded when a local anesthetic is used?
Brand, percentage of solution, type and ratio of vasoconstrictor, and amount of anesthetic injected by cc or ml
How is the original diagnosis referred to during frequent sittings or during transfer of the patient to another facility?
By using the term Re.
The patient has mesio-occlusal caries of the maxillary left second bicuspid. Treatment consisted of removing the caries and inserting a base material (Dycal) and an amalgam (Dispersalloy) restoration with one carpule of 2 percent lidocaine (1:50,000 epinephrine) for anesthesia.
Car #13-MO B (Dycal), am (Dispersalloy), Anes 2 percent lido 1:50,000 epi 1.8cc
The patient has mesio-occlusal-distal caries of the maxillary right first molar. Treatment consisted of removing the caries and inserting a base material (Dycal) and an amalgam (Tytin) restoration with one carpule of 2 percent xylocaine (1:100,000 epinephrine) for anesthesia.
Car #3-MOD B (Dycal), am (Tytin), Anes 2 percent xylo 1:100,000 epi 1.8cc.
Oral conditions expected to result in dental emergencies within 12 months if not treated.
Class 3
Periodontal abscess.
Class 3
What information is entered in item 8 of the SF 603? How are entries made in item 8?
Chart all restorations completed during the person's military service. Use the symbols provided for the charting of Missing Teeth and Existing Restorations, and black or blue black ink to chart the restorations as they are completed.
What information is entered in item 9 of the SF 603? How are entries made in item 9?
Chart the diseases and abnormalities found subsequent to the date (found after the date) of the original examination. Use the same symbols used to chart diseases and abnormalities and pencil to permit erasures of symbols as dental treatment is completed.
Arrested caries for which treatment is not indicated.
Class 1
Healthy periodontium, no bleeding on probing.
Class 1
No dental caries or defective restorations.
Class 1
Oral prophylaxis not indicated.
Class 1
Replacement of missing teeth not indicated.
Class 1
Requires no dental treatment or reevaluation within 12 months.
Class 1
When patients require only an oral prophylaxis to update the AFDRAP, what statement is entered on the SF 603/603A? Explain why.
Class 1 after pro. The statement is entered on the SF 603/603A as the last item for that visit.
Active orthodontic treatment.
Class 2
Early or mild adult periodontitis.
Class 2
Edentulous areas requiring prostheses but not immediately.
Class 2
Nonspecific gingivitis.
Class 2
Oral conditions no expected to result in dental emergencies within 12 months if not treated.
Class 2
Requirement for maintenance therapy.
Class 2
Requirement for oral prophylaxis.
Class 2
Supragingival or slight subgingival calculus.
Class 2
Active moderate to advanced periodontitis.
Class 3
Acute gingivitis or pericoronitis.
Class 3
Edentulous areas or teeth requiring immediate prosthodontic treatment.
Class 3
Lesions requiring biopsy or awaiting biopsy report.
Class 3
Moderate to heavy subgingival calculus.
Class 3
The patient has a defective mesio-occlusal-distal restoration on the deciduous mandibular left second molar. Treatment consisted of removing and replacing the amalgam restoration. The following materials were used in treatment: Dycal as base, Dispersalloy amalgam and one carpule of 2 percent xylocaine (100,000 epinephrine).
Def res K-MOD B (Dycal), am (Dispersalloy), Anes 2 percent xylocaine 100,000 epi 1.8cc
In what sequence is information recorded?
Diagnosis, location, and treatment
When is it necessary to record the treatment facility in item 10?
Each time the patient changes facilities
Briefly state what information is recorded in item 10 of the SF 603.
Enter chronologically the date of the visit (day, month, and year), all diagnoses made, all treatment provided, and the class of all active duty patients
Briefly explain what a type 2 examination includes.
Examination of all oral hard and soft tissues using a periodontal probe, mouth-mirror, and explorer; bite-wing, panoramic, or other radiographs as professionally indicated; recording of an initial treatment plan, and Air Force Periodontal Screening and Recording Index
When performing a type 5 screening examination to initiate a record, what entries are made in section I, items 4 and 5?
In Item 4, Remarks, enter the statement: "Dental in-processing, panoramic radiograph, the date, and base." Items 4 and 5 require no further entries at this time. When the individual first reports for dental treatment, section 1, items 4 and 5 are charted and completed.
Where are PSR scores and/or indices documented?
In item 10 of the SF 603/603A
What entry is required if a charted prosthesis does not replace the exact number of teeth indicated?
In the "Remark" block of item 4, enter the number of teeth actually in the prosthesis
Briefly state the function of the SF 603.
It is the basic permanent record of a patient's dental health and the treatment provided. It serves as a chronological record of the patient's oral health; shows the patient's initial dental condition, the treatment received, and the current oral health status; and can also be used for identification of deceased individuals
What items are included in section II of the SF 603?
Item 8, Restorations and Treatments; item 9, Subsequent Diseases and Abnormalities; and item 10, Services Provided
When numbering permanent teeth, which tooth is #1?
Maxillary right third molar
What is used to identify specific teeth and tooth surfaces?
Numbers are used to identify specific permanent teeth and upper case letters for primary teeth. Tooth surfaces are identified using letters
Where are significant findings from a medical laboratory or radiographic request recorded
On the SF 603 or 603A in Item 10.
What additional actions are required when the SF 515 is returned?
One copy of the SF 515 must be placed in the dental health record. The following information must be recorded on the SF 603 or 603A, Item 10: (1) Date the dental service receives the SF 515 from the oral histopathology center. (2) Name of the oral histopathology center providing the report. (3) Oral histopathology center accession number, anatomic site, and diagnosis. (4) Date and method of notifying the patient. (5) Date of follow-up, if applicable.
When is information entered in the following blocks of item 4: "Place and Date of the Examination" and "Signature of Examining Dentist"?
Only when the examining dentist is different from block 7.
In addition to the list of authorized abbreviations, what other abbreviations may be used?
Recognized AF office symbols, abbreviations for organizational designations, and standard pharmacy abbreviations
Briefly state what action is required when a patient received treatment at a location other than the base of assignment or record location.
Record any treatment and the name of the military or civilian agencies where the patient received unrecorded services
What form is frequently used for medical consultation or treatment planning?
SF 513, Medical Record-Consultation Sheet
What forms are used to submit oral specimens to the oral histopathology center?
SF 515, Medical Record-Tissue Examination
At whose request does a dentist accomplish a postmortem examination? What type of radiographs are normally part of this examination?
The DBMS, aircraft mishap board medical officer, Air Force mortuary service or base mortuary officer, or Armed Forces Institute of Pathology Aviation Pathology team. A full mouth postmortem dental radiographic series
Briefly explain what actions are required if an active duty patient refuses dental treatment.
The DSC must explain the value and necessity of proper oral health care to the patient who refuses treatment. If the member still refuses dental care, the DSC must report the refusal in writing of care to the person's commander. This includes a statement of the possible effects the dental condition may have on the individual's performance of duty and readiness capability. Record actions taken in the patient's dental health record on SF 603/603A. For patients in dental readiness class 3 or 4, an AF Form 422, Notification of AF Members Qualifications Status, is sent to the Physical Examination Section.
What actions are necessary when an SF 513, used for a medical consultation, is returned by the consultant?
The SF 513 becomes a permanent part of the patient's dental health record. Findings and recommendations are recorded on the SF 603/603A in item 10.
What actions are necessary when PH notifies the dental service of a patient with a communicable disease?
The completed AF Form 570 is placed in the patient's dental record until PH advises otherwise. The name of the disease is placed on the AF Form 696 by the dental service
What action is taken if the disqualifying defects cannot be corrected prior to the patient's expected departure?
The examining dentist forwards an AF Form 422, Notification of AF Members Qualifications Status, noting restrictions and instructions to the physical examination section
Who verifies and signs each entry made in item 10?
The health care provider or technician who performed the service verifies and signs each entry.
What information must be entered if the "Other" block in item 1 is used?
The specific purpose of the examination, such as no record available, short tour, temporary record, or dental identification
When entering the SSN on records of family members, whose SSN is entered?
The sponsor's.
What action is taken when patients have a malignant diagnosis?
They are enrolled in the USAF Tumor Registry
What is the purpose of a periodic dental examination and what should it include?
To assess the dental readiness status of active duty AF personnel. At a minimum, it includes a type 2 examination and a review of dental health records. Combined examination and oral prophylaxis appointments are encouraged.
What is the purpose of the AF PSR index?
To identify and provide a chronological record of the patient's periodontal and oral hygiene status. Provide meaningful soft tissue and oral hygiene profiles for each patient. Facilitate the routing of patients to providers of the appropriate skill level
When is a type 5 examination performed?
To initiate a member's dental record
What is the purpose of using abbreviations?
To save space on dental treatment forms and to ensure uniformity
What types of examinations are performed when a dental health record is initiated because a record was never initiated or was lost?
Type 1, 2, or 5
What type of examination may be performed as an extensive examination of all hard and soft tissues, periodontal probing of all existing teeth, review of new or existing full-mouth intraoral periapical, or panoramic radiographs with posterior bitewing radiographs, and formulation of a comprehensive treatment plan?
Type 1—Comprehensive
What minimum type of examination is necessary when charting item 4 of the dental health record? What does this portion of the record indicate?
Type 2. All missing teeth and restorations at the time of the original examination
What dental readiness classification disqualifies a patient from a remote clearance?
Type 3.
What type of examination may include a generalized examination of all hard and soft tissues?
Type 3—Other examination
What types of dental examinations may be performed by a qualified dental assistant or dental hygienist?
Types 4 and 5.
What are the purposes of using a dental readiness classification system?
Uniform system of recording results of a dental examination. Lets the provider determine the dental status of each individual. Establishes priorities of treatment. Keeps the DSC informed of the dental health status of active duty personnel on base
When are items 4 and 5 completed for AF military personnel?
Upon initiation of treatment following a type 5 examination, or whenever the SF 603 is serving as the permanent record
What entries are required for implant and periodontal maintenance patients?
Using approximately 1/8-inch red letters, identify implant and periodontal maintenance patients in the "Remarks" area of this item. Bring this identification forward on all subsequent SFs 603A
When is section I of the SF 603 completed?
When definitive care is provided to any patient (except the Children's Preventive Dentistry Program
When is the SF 603A used? What charting symbols are transferred to the SF 603A?
When space is no longer available for entering the treatment provided in item 10. Only transfer charting symbols of the current treatment requirements in item 9.
