| 9-1/0023 |
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REPUBLIC
OF NAMIBIA MINISTRY OF HEALTH AND SOCIAL SERVICES |
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| (Rev. 08/00) |
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Health Information System 2000
(HIS2K) |
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DENTAL HEALTH SERVICES MONTHLY SUMMARY
REPORT FORM |
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| Report For
Month Of ________________ Year:
__________ |
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| Facility
Name: ___________________________
Type ( 4 ONE ) :
___Hospital ___ H/C ___Clinic |
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4 = No Dental Health
Services Provided This Month |
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| 1. Total Number Of Outpatient Dental Visits
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1 |
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| DENTAL
TREATMENT |
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| 2. Total Number Of Extractions (Teeth
Extracted) ..
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2 |
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| 3. Total Number Of Fillings (any type) Done
(Teeth Filled)
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3 |
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| 4. Total Number Patients Receiving A Flouride
Application
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4 |
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| 5. Total Number Of Scaling and Polishing
(Sextants)
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5 |
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| 6. Total Number Of Patients Treated For Soft
Tissue Lesions
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6 |
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| 7. Total Number Of Inter Maxillary Fixations
(IMF)
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7 |
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| 8. Total Number Of Full Dentures Produced
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8 |
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| 9. Total Number Of Partial Dentures
Produced
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9 |
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| 10.
Total Number of Dentures Repaired
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10 |
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| DENTAL
DIAGNOSES (No. Of Patients Diagnosed With...) |
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| 11.
Caries
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11 |
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| 12.
Peridontal Disease
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12 |
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| 13.
Tooth Abscess
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13 |
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| 14.
Dry Socket
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14 |
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| 15.
Oral Cancer
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15 |
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| 16.
Impactions
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16 |
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| 17 Fractures of the
Jaw
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17 |
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| 18.
Other
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18 |
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| X-RAY
EXAMINATIONS |
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| 19.
Total Number of Intra oral x-ray examinations
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19 |
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| 20.
Total Number of Extra-oral x-ray examinations
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20 |
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| REFERRALS |
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| 21.
Total Number Of Referrals Received FROM Other Facility
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21 |
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| 22.
Total Number of Referrals Made TO
Other Facility
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22 |
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| OUTREACH/SMILING
SCHOOLS ACTIVITIES |
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Planned |
Done |
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| 23.
Total Number of visits to Outreach Points
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23 |
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| 24.
Total Number of visits/rounds to Smiling Schools
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24 |
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