Dental Record Administration Recording And Appointment Control

This bulletin provides instructions for the uniform completion and maintenance of the Health Record-Dental, to include examples of forms that are found within or affecting the content of the record. Instructions are provided for the uniform recording of initial dental processing, dental examinations, diagnoses, and treatments in the SF 603 (Health Record-Dental) and SF 603A (Health Record-Dental-Continuation), as well as the recording of the patient health history. Current abbreviations and terms useful in completing the SF 603 and SF 603A are contained in the appendixes. The Terminal Digit Filing System (TDFS) and the dental record jacket (DA Forms 3444) are explained. A discussion of appointment control and workload reporting throughout the U.S. Army is also included. The dental health record is a permanent document designed to furnish a comprehensive dental history of each individual. Dental health record management serves as a critical element in the welfare of dental patients and the success of the U.S. Army Dental Corps in ensuring dental health and readiness of soldiers to fight and win in the battlefield. Excellence in record management requires a commitment to standardization in format and a persistent, diligent quest for accuracy and completeness. The dental record serves for treatment planning and documentation, forensic, legal, dental classification, and quality assurance purposes. All entries must be accurate, complete, and concise if the best interest of the patient, the Government, and the dental care provider are to be served. Effective professional communication and documentation via the dental health record accomplished by the conscientious use of the standardized format (see AR 40-66), represents a cornerstone of quality dental care. This document is designed to be a reference for dental care providers throughout the Army Medical Department (AMEDD) as well as an instruction manual for dental health providers newly accessed to the Army Dental Care System (ADCS).