Exemplar use only
Unit 3: Supplementary Outcome Appendix K
Record all of the information below onto the charting system used within your clinical environment. If
this is captured with a paper template then you will need to take a picture of the completed chart or
scan it and then upload and attach the chart to the 'Completed Forensic Chart' evidence field below.
If your chart is already in an electronic format then please upload and attach the file to PebblePad and
attach the chart to the 'Completed Forensic Chart' evidence field below.
a) 18 is partially erupted j) 26 is to be extracted
b) 17 has an occlusal restoration k) 28 is un-erupted
l) 38 is missing
c) 16 has an occluso-palatal restoration,
m) 37 has an occlusal cavity
needs replacing n) 34 has a full gold crown
d) 14 is missing and the gap has closed o) 32 has a disto-labial restoration
p) 41 has a disto-labial cavity
e) 13 has a porcelain jacket crown in place
q) 44 has a mesial-occlusal-buccal
f) 12 has a fracture of the incisal edge cavity
g) 21 needs a disto-palatal restoration r) 85 is retained
h) 24 is root filled with an occlusal restoration
i) 25 has a mesial-occlusal-distal cavity
Picture on second page
Unit 3: Supplementary Outcome Appendix K
Record all of the information below onto the charting system used within your clinical environment. If
this is captured with a paper template then you will need to take a picture of the completed chart or
scan it and then upload and attach the chart to the 'Completed Forensic Chart' evidence field below.
If your chart is already in an electronic format then please upload and attach the file to PebblePad and
attach the chart to the 'Completed Forensic Chart' evidence field below.
a) 18 is partially erupted j) 26 is to be extracted
b) 17 has an occlusal restoration k) 28 is un-erupted
l) 38 is missing
c) 16 has an occluso-palatal restoration,
m) 37 has an occlusal cavity
needs replacing n) 34 has a full gold crown
d) 14 is missing and the gap has closed o) 32 has a disto-labial restoration
p) 41 has a disto-labial cavity
e) 13 has a porcelain jacket crown in place
q) 44 has a mesial-occlusal-buccal
f) 12 has a fracture of the incisal edge cavity
g) 21 needs a disto-palatal restoration r) 85 is retained
h) 24 is root filled with an occlusal restoration
i) 25 has a mesial-occlusal-distal cavity
Picture on second page
