b. Records. As in all patient treatment areas, the dental specialist in the oral
medicine and treatment planning service should ensure, when treating the patient, that
the correct records for the patient have been provided. As the dental officer conducts the
examination, he will state his initial findings and the dental specialist will record these
findings on applicable charts and sections of the various forms used. The dental
specialist in the oral medicine and treatment planning service must be proficient in
recording examinations and know the provisions of publications that cover prescribed
forms, know authorized terms and abbreviations, know methods of recording, and know
dental classifications. The publications covering dental examinations and records are AR
40-3, AR 40-501, and TB MED 250.
1-13. MEDICAL HISTORIES
a. General. Any dental examination includes taking and recording the patient's
medical history. The medical history may be brief or detailed, depending upon the findings
and observations made during the examination. The history consists mainly of information
pertinent to the conditions revealed during the examination and is obtained from the patient
by questions asked by the dental officer. A medical history should be updated at every
b. Importance of Medical Histories. The following are four important functions
of patient medical histories.
Provide important information that assists the dental officer in arriving at a
(2) Provide information on conditions that might lead to complications during
treatment procedures if not previously recognized.
Establish good rapport with the patient.
Provide a good opportunity for patient education.
c. Taking and Recording Histories. Pertinent information brought out while
taking the patient's history should be recorded in writing. In taking a history, the dental
officer often has an established routine that he conscientiously follows so that no possible
information is overlooked. He may take brief notes and later write the summary to be
recorded or transcribed as part of the patient's record.
d. Ethical Aspects. Information given by the patient to the dental officer is
confidential and is used to enhance professional care. The dental specialist will not
reveal confidential information to any person not concerned with the patient's medical or