©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCWDO1 ;ALB/CMM DENTAL AND ORAL WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;Narrative: Regional Office action is required for all dental treatment
;;based on combat wounds, service trauma, prisoner of war or extracted
;;teeth under 38 CFR 17.123.
;;
;;A. Review of Medical Records:
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe:
;; 1. Describe extent of functional impairment due to loss of motion
;; and masticatory function loss.
;;
;;
;; 2. Describe the extent and number of missing teeth and whether
;; the masticatory surface can be replaced by a prosthesis.
;;
;;
;; 3. If limitation of inter-incisal range of motion, provide actual
;; range in mm (i.e., 0-Xmm) and also provide lateral excursion
;; (i.e., 0-Xmm).
;;
;;
;; 4. Describe the extent of any bone loss of mandible, maxilla, or
;; hard palate. For hard palate and maxilla bone loss, state
;; whether replaceable by prosthesis.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; Provide:
;; 1. X-ray to determine extent of bone tissue loss.
;; 2. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;TOF
;;E. Diagnosis:
;;
;; 1. Give etiology where there is loss of teeth due to loss of
;; substance of body of maxilla or mandible.
;;
;;
;;Signature: Date:
;;END