Standard Form 603A (SF 603A): Medical Record - Dental - Continuation

Standard Form 603A (SF 603A), Medical Record - Dental - Continuation, is a two-sided dental record sheet, Rev. 11/2002. Its footer reads Prescribed by GSA/ICMR FMR (41 CFR) 102-194.30(i), and GSA hosts a copy in its forms library. The form says the previous edition is not usable and that it is authorized for local reproduction.

Both sides print Section III, Attendance Record: item 15 for restorations and treatments completed during service and item 16 for subsequent diseases and abnormalities, each with a tooth chart numbered 1 to 32 and a remarks box, and item 17, a table of services rendered. The front ends with blocks for the sponsor, the facility and the patient's identification, and the back has a line for the patient's name and ID number. These are the same section and item numbers as the back of SF 603, Health Record - Dental.

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Top of page 1 of Standard Form 603A (SF 603A): Medical Record - Dental - Continuation, as printed by GSA

What's on SF 603A

Item 15: restorations and treatments

A tooth chart numbered 1 to 32 and marked right and left for restorations and treatments completed during service, with a remarks box.

Item 16: subsequent diseases and abnormalities

A second tooth chart for subsequent diseases and abnormalities, with its own remarks box.

Item 17: services rendered

A ruled table with date, diagnosis and treatment, class, operator and dental facility, and initials.

Sponsor and facility blocks

Relationship to sponsor, sponsor's name and ID number, department or service, hospital or medical facility and records maintained at.

Patient's identification

Name (last, first, middle), ID no. (SSN or other) and hospital or medical facility, next to a register number and a ward number.

Back of the form

A line for last name, first name, middle initial and ID number, then Section III with items 15 to 17 again.

How to complete SF 603A

1
Identify the patient
Fill in the patient's identification on the front, plus the register and ward numbers, and the name and ID number line on the back.
2
Fill in the sponsor and facility
Enter the relationship to sponsor, the sponsor's name and ID number, the department or service, the facility and where records are maintained.
3
Mark the charts
Mark restorations and treatments on the item 15 chart and subsequent diseases and abnormalities on the item 16 chart, with remarks.
4
Log each service
Add a row to item 17 for each service, with the date, diagnosis and treatment, class, operator and dental facility, and initials.
5
Continue on the back
The back repeats items 15 to 17 for more entries.

The form prints no instructions beyond its blocks. These steps follow them.

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Records and what the form says

Where it goes

The PDF gives no filing address or routing instructions. It has a Records Maintained At block.

Edition and copies

The form says the previous edition is not usable and that it is authorized for local reproduction. The footer reads STANDARD FORM 603A (REV. 11/2002), and GSA's page lists the current revision date as 11/2002.

Same items as SF 603

The PDF does not name the form it continues. Its Section III and items 15 to 17 match the back of SF 603, Health Record - Dental.

Who uses SF 603A?

Dental operators
Each row of item 17, Services Rendered, records the date, diagnosis and treatment, class, operator and dental facility, and initials.
The patient
For typed or written entries, the patient's identification asks for the name (last, first, middle), ID no. (SSN or other) and hospital or medical facility.
The sponsor
Blocks ask for the relationship to sponsor, the sponsor's last name, first name and middle initial, and the sponsor's ID number (SSN or Other).
The hospital or medical facility
The front names the department or service, the hospital or medical facility and where records are maintained, with a register number and a ward number.

The form does not say in words who fills it out. Its blocks name these people and places.

Official sources and the blank

Official GSA form page
The agency’s own page for Form SF603A.
Blank PDF
The official blank form, to print or fill by hand.

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Questions about Form SF603A

Who prescribes SF 603A?

The footer reads Prescribed by GSA/ICMR FMR (41 CFR) 102-194.30(i). GSA hosts a copy in its forms library.

What does SF 603A continue?

The PDF does not name the form it continues. It is headed Dental - Continuation and prints Section III, Attendance Record, items 15 to 17, the same as the back of SF 603, Health Record - Dental.

How are the teeth numbered on SF 603A?

Each chart numbers the teeth 1 to 16 on the upper row and 17 to 32 on the lower row, with RIGHT and LEFT printed at the ends.

Can an older edition of SF 603A be used?

The form says the previous edition is not usable. The edition GSA hosts is STANDARD FORM 603A (REV. 11/2002), and it is authorized for local reproduction.

Standard Form 603A (SF 603A): Medical Record - Dental - Continuation