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["项目","牙位","模版示例(该文档内容为示例,请根据实际诊断病历填写内容)","备注"]
["主诉",null," 牙{发黑、有洞、龋洞} {1、2、3、6} 个月","{}内文字为可变项，同时多个可变项用'、'隔开"]
["现病史",null,"{3个月}来，患者牙{发黑}，否认自发痛、夜间痛、冷热刺激痛。自述{未曾治疗}，要求{检查}。","牙位字段为数据代替，无需填写"]
["既往史",null,"{否认特殊}"]
["家族史",null,"{否认特殊}"]
["过敏史",null,"{体健}，{否认过敏史}"]
["检查",null,"{面窝沟}可见{龋损}，质{软}，{无}探痛，冷测正常，未及露髓孔，叩痛（-），{不}松动，牙龈{无}红肿，根尖区无红肿，{颊侧}无窦道口，扪痛（-）。"]
["X线片示（影像）",null,"{面未见低密度影}，根管内未见充填物影像，根尖周未见低密度影，牙槽骨{未见明显吸收}。\n口腔卫生状况{一般}，牙石{（+）}，色素{（+）}"]
["诊断",null,"浅龋"]
["治疗计划",null,"直接充填治疗 OHI 牙周系统治疗"]
["处置（基础模版公用）",null,"1.向患者交代病情、治疗计划、费用及自费比例、并发症、疗程及预后等，患者知情同意、要求治疗"]
["处置",null,"2.{上橡皮障}，微创车针去腐净达{牙釉质层}，洞型设计，牙体预备。隔湿干燥，比色，{排龈}，{上邻面修复系统}，自酸蚀系统粘接，{流动树脂+纳米树脂}充填，{调}，抛光。"]
["医嘱",null,"3.医嘱，勿咬硬物，不适随诊。{建议半年复查}。"]