oral health record protocols - nsw · in such areas of odontogram, charting techniques and...

Policy Directive

Ministry of Health, NSW73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

spacespace

Oral Health Record Protocols - NSWspace

Document Number PD2008_024

Publication date 05-May-2008

Functional Sub group Clinical/ Patient Services - Dental/Oral

Summary The NSW Oral Health Record Protocols identify a good practice standardfor clinical record documentation by oral health clinicians and aninformation source for complaints and risk management.

Author Branch Centre for Oral Health Strategy

Branch contact Jennifer Conquest 8821 4311

Applies to Area Health Services/Chief Executive Governed Statutory HealthCorporation, Board Governed Statutory Health Corporations, DentalSchools and Clinics, Public Health Units

Audience Dental clinical staff, dentistry students, dental assistant trainees,scholarship students

Distributed to Public Health System, Dental Schools and Clinics, Ministry of Health,Public Health Units, Tertiary Education Institutes

Review date 05-May-2010

Policy Manual Not applicable

File No. H07/106015

Status Rescinded

Rescinded By GL2015_017

Director-GeneralspaceThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatoryfor NSW Health and is a condition of subsidy for public health organisations.

Policy Directive

Department of Health, NSW73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

spacespace

Oral Health Record Protocols - NSWspace

Document Number PD2008_024

Publication date 05-May-2008

Functional Sub group Clinical/ Patient Services - Dental/Oral

Summary The NSW Oral Health Record Protocols identify a good practice standardfor clinical record documentation by oral health clinicians and aninformation source for complaints and risk management.

Author Branch Centre for Oral Health Strategy

Branch contact Jennifer Conquest 8821 4311

Applies to Area Health Services/Chief Executive Governed Statutory HealthCorporation, Board Governed Statutory Health Corporations, DentalSchools and Clinics, Public Health Units

Audience Dental clinical staff, dentistry students, dental assistant trainees,scholarship students

Distributed to Public Health System, Dental Schools and Clinics, NSW Department ofHealth, Public Health Units, Tertiary Education Institutes

Review date 05-May-2010

File No. H07/106015

Status Active

Director-GeneralspaceThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatoryfor NSW Health and is a condition of subsidy for public health organisations.

NSW Oral Health Record Protocols

NSW DEPARTMENT OF HEALTH

NSW Department of Health

Locked Mail Bag 961

North Sydney NSW 2060

Tel. (02) 9391 9030

Fax. (02) 9391 9468

www.health.nsw.gov.au

© NSW Department of Health 2006

Published by Centre for Oral Health NSW. All rights reserved.

SHPN (PH) 060017

ISBN 0 7347 3905 2

Further copies of this document can be downloaded from the

NSW Health website: www.health.nsw.gov.au

March 2008

NSW Oral Health Record Protocols NSW Health PAGE i

Foreword ................................................................................................................ii

1. Introduction .......................................................................................................1

1.1 Purpose.........................................................................................................................1

1.2 Scope............................................................................................................................1

1.3 Application of Policy......................................................................................................1

1.4 Evaluation process.........................................................................................................2

2. Key elements .....................................................................................................3

2.1 Patient identification .....................................................................................................3

2.2 Medical history..............................................................................................................3

2.3 Consent for treatment ..................................................................................................3

2.4 Emergency care.............................................................................................................3

2.5 Authorities ....................................................................................................................3

2.6 Examinations and treatment plan for a course of care...................................................3

2.7 Charting and tooth identification ..................................................................................4

2.8 Prevention.....................................................................................................................4

2.9 Anaesthetics..................................................................................................................4

2.10 Restorations ..................................................................................................................4

2.11 Exodontia......................................................................................................................4

2.12 Minor oral surgery.........................................................................................................4

2.13 Medication....................................................................................................................4

2.14 Sign off .........................................................................................................................5

2.15 Sterilisation tracking......................................................................................................5

2.16 Data collection ..............................................................................................................5

2.17 Open disclosure.............................................................................................................5

2.18 Abbreviations ................................................................................................................5

3. Acronyms............................................................................................................6

4. References ..........................................................................................................7

APPENDIX A Definition of terms..............................................................................................8

APPENDIX B Medical History ....................................................................................................9

APPENDIX C Federation Dentaire Internationale (FDI).........................................................12

APPENDIX D Terms, Abbreviations and Symbols..................................................................13

Contents

PAGE ii NSW Oral Health Record Protocols NSW Health

It was identified by Area Health Services that there were gaps with the current documentation of patient records.

Through collaborative consultation and feedback with oral health professionals an Oral Health Record Protocols Policy

Directive has been developed to ensure that oral health care providers within NSW Health maintain records that meet

NSW Dental Board standards (NSW 1998) and serve in the best interest of their patients by ensuring patient safety

and continuity of patient care.

The NSW Oral Health Record Protocols Policy Directive has been prepared by the Centre for Oral Health Strategy

NSW and by the State Clinical Advisory Group (CAG). Ideas and recommendations have also been made to the

document from Area Health Services and the State Oral Health Executive (SOHE).

The SOHE endorsed the development of an Oral Health record on 17 May 2005.

The Centre for Oral Health Strategy NSW is grateful to the contributions made by Associate Professor Peter Dennison

with regards to agreeing to the use of the 'root surface' odontogram (Dennison, P 1999). Many thanks also go

to Professor Christopher Griffith for his input and members of the Centre for Oral Health Strategy NSW who edited

the final copy of this document.

The Oral Health Record Protocols Policy Directive take a contemporary view of patient centred care and consider the

significance of the history taking procedure and it's relationship to appropriate treatment, including treatment sequence.

Implementing the Oral Health Record Protocols as a policy directive will result in a review of current work practices

in such areas of odontogram, charting techniques and abbreviations. This policy directive will ensure that all

Oral Health providers produce high quality, comprehensive care by documenting detailed and relevant patient

information both current and historical as a Best Clinical Practice model.

Dr Clive Wright

Chief Dental Officer

Centre for Oral Health Strategy NSW

Foreword

NSW Oral Health Record Protocols NSW Health PAGE 1

SECTION 1

Introduction

Accurate diagnostic information forms the foundation

of any treatment plan. This information comes from

several sources – the patient history, radiographs,

and clinical examination. A thorough patient

assessment will assist in formulating a series of

treatment that will benefit the patient and provide

them with optimal care.

New South Wales (NSW) Health is committed to

ensuring record keeping standards are generic

across the State. The development of the NSW Oral

Health Record Protocols Policy Directive (OHR) is to

address the need to establish a best practice model

across NSW.

This best practice model for OHR contains the

following three components:

i) key elements

ii) medical history templates

iii) charting and abbreviations.

1.1 Purpose

The OHR provide clarity in good practice standards

for clinical record documentation by oral health

clinicians and an information source for complaints

and risk management that can be adapted to Area

Health Service requirements.

1.2 Scope

The scope of OHR is to:

■ Cover patient record work practices of both paper

based and electronic

■ Ensure that there has been no duplication and/or

overlap using existing NSW Health policies and

procedures

■ Enhance the NSW Dental Board Standards

(NSW 1998)

1.3 Application of PolicyWhat other documents is this Policy Directive

related to?

This policy directive (PD) should be read in

conjunction with:

i) PD2005_406 "Consent to Medical Treatment

– Patient Information"

ii) PD2007_079 Patient Identification – Correct

Patient, Correct Procedure and Correct Site

Model Policy

iii) Guideline (GL) 2005_037 Oral Health Infection

Control Guidelines

iv) PD 2005-291 NSW Oral Health Services Activity

Reporting

v) GL 2005_032 NSW Multilingual Health Resources

by AHS, DOH and NGOs funded by NSW Health

(guidelines for Production)

vi) PD 2005_291 'Oral Health Services – Activity

Reporting'

vii) PD 2006_087 Oral Health Fee for Service Scheme

viii)PD 2007_040 Open Disclosure and

GL 2007_007 Open Disclosure Guidelines

ix) PD2007_008 Pit and Fissure Sealants;

Use of in Oral Health Services NSW

x) PD 2007_036 Infection Control Policy.

The above policy directives and guidelines have

been incorporated in this document in the related

clinical work practices of an OHR.

It is the role and responsibilities of treating clinicians

to read NSW policy protocols in full and implement

them accordingly.

NSW Oral Health Record Protocols NSW Health

Who does this apply to?

The policy directive is to assist:

■ Dental Specialists

■ Dental Officers

■ Dental Therapists

■ Dental Prosthetists

■ Dental Technicians

■ Dental Assistants

■ Dental Hygienists

■ Oral Health Therapists

■ Bachelor Oral Health students

■ Bachelor of Dentistry students

■ Dental Assistant Traineeship

■ Scholarship students.

OHR key elements

The adoption of the OHR by Area Health Services must

include the key elements identified in this document.

The key elements are as follows:

■ patient identification

■ medical history

■ consent to treatment

■ emergency care

■ authorities

■ examinations and treatment plan for a

course of care

■ charting and tooth identification

■ prevention

■ anaesthetics

■ restorations

■ exodontia

■ minor oral surgery

■ medication

■ sign off

■ sterilisation tracking

■ data collection

■ generic abbreviations

Definition of terms

The definition of terms (Appendix A) provides an

explanation of OHR (paper and electronic) work

practices (COHS 2007).

1.4 Evaluation process

The evaluation process for this policy directive is

through SOHE. The evaluation review is to be on a

biyearly cycle or as identified by Department of Health.

Area Health Services are an accredited organisation

and therefore it is recommended that the

implementation of this policy be reviewed through

this quality process such as The Australian Council

of Healthcare Standards1 Clinical Indicator Users

Manual 2007, Oral Health Indicator Area 3,

Patient Record Audits1

(ACHS 2007) or similar.

1 http://www.achs.org.au


The key elements have been broken up into clinical

work practices that pertain to a patient's oral health

record to enhance the NSW Dental Board standards.

2.1 Patient Identification

Patient identification by the treating clinician needs

to be in compliance with NSW Health Patient

Identification – Correct Patient, Correct Procedure

and Correct Site Model Policy2.

2.2 Medical History

The patient dental record should document a medical

history as taken by the clinician. Appendix B examples

1 and 2 provide medical history templates.

A medical history should include the following

elements:

a) Positive and negative responses

b) Medical history updates are to be completed

at the beginning of each course of care, check

verbally noting any changes. For clarity a new

medical history maybe documented

c) Medical history updates to be completed if

there are any changes to the patient's health

d) Each clinician has to ensure and sign off that

the medical history is completed to his or

her satisfaction

e) Any adverse reactions, allergies, or events

f) Where medical history details are recorded by

the patient as part of the registration process,

it is the lead clinicians responsibility to check

the medical history when the patient is received

in the clinic.

2.3 Consent for treatment

Obtaining consent for treatment needs to be in

compliance with the NSW Health 'Consent to Medical

Treatment – Patient Information3, and NSW Multiingual

Health Resources by AHS, DOH and NGOs funded by

NSW Health4

(guidelines for Production).

2.4 Emergency care

Clinical notes should indicate the following elements.

a) Chief complaint/reason for attendance

b) Diagnostic data

c) Radiographs taken

d) Results of tests

e) Clinical findings

f) Management plan or treatment given .

2.5 Authorities

The recording of the provision of an authority is

governed under the Oral Health Fee for Service

Scheme.

2.6 Examinations and treatment planfor a course of care

Clinical notes should indicate the following elements.

a) Presenting complaint

b) Full dental charting of dentition on examination

when providing a full course of care.

c) A separate charting of treatment required

(which may be amended to note the progress

of treatment)

d) Notes regarding soft tissues, extra-oral findings,

intra-oral findings, and periodontal health

e) A treatment plan of appropriate detail

f) Past dental history.

2 http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf3 http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf4 http://www.health.nsw.gov.au/policies/GL/2005/pdf/PD2005_032.pdf

SECTION 2

Key elements


2.7 Charting and tooth identification

In Appendix C the Federation Dentaire Internationale

(FDI) notation for recording tooth number is to be used.

a) The odoontogram for permanent teeth should

have root surfaces. A deciduous odontogram

should be available where applicable. The outline

of the odontogram should be a colour that

contrasts with black ink.

b) A standard set of charting symbols for the

recording of dentition is to be used.

c) In charting, the materials used in restorations

should be indicated as follows:

i. Amalgam is solid filled and black

ii. Gold is vertical striping

iii. Tooth coloured restoration is diagonal

striping from lower left to upper right

d) Periodontal charting:

i. Additional forms should be used for the

recording of pocket depth, gingival health

relating to cemento-enamel junction,

gingival bleeding index as required.

ii. The prudent documentation of gingival

health is important when considering a full

course of care.

2.8 Prevention

In providing preventative treatment the NSW Health

policy directive on Pit and Fissure Sealants: Use of in

Oral Health Services NSW5 applies.

2.9 Anaesthetics

Clinical notes should indicate the following elements:

a) Type of anaesthetic used

b) Amount of anaesthetic used

c) Type of injection given

d) Any adverse reactions, allergies, or events.

2.10 Restorations


a) Tooth involved

b) Surface/s involved

c) Base/linings used

d) Restoration material and shades used

e) Unusual depth or other features.

2.11 Exodontia


a) The tooth extracted

b) Reasons for extraction

c) Any complications

d) An indication if post operative instructions

were given

e) An indication if haemostasis has been achieved.

2.12 Minor oral surgery


a) Reason for procedure

b) Procedure undertaken including technique used

c) Supporting test/data/symptoms

d) An indication if post operative instructions

were given.

2.13 Medication


a) The type of medication prescribed

b) The dose of medication and indication of the

method of delivery

c) If antibiotic prophylaxis is used, the time of

administration and the time of commencement

of treatment

d) Any adverse reactions, allergies, or events.

5 http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_008.pdf


2.14 Sign off

The sign off process must be in accordance within

the scopes of the practice of the treating clinician,

such as patients treated by dental students require

both students and tutors signatures. Each provider

is to write their name, designation, sign and date

every entry in the clinical notes. In the instance

of an electronic OHR the following functionalities

can be used for the sign off:

a) An electronic signature pad.

b) The treating clinician's pin and password.

c) Scanning and storage of a treating clinician's

signature (COHS 2007).

2.15 Sterilisation tracking

Recording of sterilisation process are to be in

accordance with NSW Health 'Oral Health Infection

Control Guidelines for Oral Health Care Settings'6

and Infection Control Policy.7

2.16 Data collection

Data collection is an important component to

analysing service delivery and assessing the oral health

needs of populations. The policy directive to refer

to is 'NSW Oral Health Services Activity Reporting.8

2.17 Open disclosure

It is important to establish a generic approach for

communication between patient and clinician after

an incident occurs. The NSW Health procedures are

identified in 'Open Disclosure'9 and GL 2007_007

Open Disclosure Guidelines.10

2.18 Abbreviations

Table A in Appendix D provides a list of approved

oral health terms. When these terms are not

abbreviated, they should be written in full.

6 http://www.health.nsw.gov.au/policies/GL/2005/pdf/GL2005_037.pdf7 http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf8 http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_291.pdf9 http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_040.pdf10 http://www.health.nsw.gov.au/policies/gl/2005/pdf/GL2007_007.pdf


CAG Clinical Advisory Group

COHS Centre for Oral Health Strategy NSW

GL Guideline

NSW New South Wales

OHR Oral Health Record

PD Policy directive

SOHE State Oral Health Executive

SECTION 3

Acronyms


Centre for Oral Health Stategy NSW 2007. Information

System for Oral Health (ISOH) Electronic Oral Health

Record Business Needs Report. Unpublished

Dennison, P 1999 A Modified Odontogram to

enable Root Surface Charting Community Oral

Health and Epidemiology, Article, Westmead Centre

for Oral Health, Faculty of Dentistry University of

Sydney Australia

NSW Dental Board 1998 Guidelines for Dental

Record Keeping, Information Sheet September 1998.

Dental Board of New South Wales

NSW Health 2003 Dental Practice Regulations

Regulating Impact Statement. Department of Health

NSW Australia

NSW Health (2004) Communicating Positively –

A Guide to appropriate Aboriginal terminology.

Better Health Centre – Publications Warehouse

Australia

NSW Department of Health 2007, Reducing healthcare

associated infections in NSW Online 10 November

2007 www.health.nsw.gov.au/quality/hai/

The Australian Council of Healthcare Standards 2007

Clinical Indicator User’s Manual 2007 Oral Health.

ACHS Publication Service Australia

Widmer, R.P. and Cameron, A.C 2003 Handbook of

Pediatric Dentistry Second Edition. Australasian

Academy of Paediatric Dentistry. Mosby Edinburgh

LondonNew York Philadelpha St Louis Sydney Toronto

SECTION 4

References


Term Definition

Referral pathway A referral pathway is the process whereby clients are referred in or out of the public system. The dental specialist or practitioner to whom the patient has been referred should complete anexamination, and record that aspect of the client's management pertinent to the area/s (COHS 2007).

Treating clinician The treating clinician is the person responsible for delivering a treatment or procedure. These workpractices may be provided by a multi skilled work force including: (i) Dental Specialists, Dentists,Dental Therapists, Dental Hygienists and Oral Health Therapists (ii) Dental Assistants skilled inradiography and oral health education (iii) allied health professionals such as Physiotherapistsand Occupational Therapists and (iv) Radiographers and Registered Nurses (COHS 2007).

Oral examination An oral examination includes the examination of both soft and hard tissues, and findings arerecorded using an odontogram and/or text. The charting needs to comply with the World DentalFederation (FDI) system and should include: (i) restored teeth (tooth code, surface/s involved andmaterials used) (ii) sound and unrestored teeth (iii) missing teeth (iv) hard tissue and soft tissueabnormalities (v) occlusion, including tooth mobility (vi) periodontal status including periodontalpocket depth, supra-gingival calculus, sub-gingival calculus and oral hygiene status and type ofprosthetic appliances present (COHS 2007).

Consent for Consent for treatment is a legal requirement which must be obtained prior to commencing treatment dental treatment. The treatment plan identifies oral conditions that will be addressed within

a course of care. The client must be able to provide informed consent by indicating that theyunderstand the (i) diagnosis (ii) proposed treatment and benefits (treatment plan) (iii) risksregarding proposed treatment and chances of success (iv) alternative forms of treatment and (v) prognosis if treatment is not provided. A signed consent form indicates that the client fully understands the information provided. If consent is refused it is to be documented,including the information given to the client, in the client's record (NSW Health 2007).

Prioritised Prioritised Treatment plan is the recording of subsequent prioritised treatments with textual treatment plan description including: (i) tooth code (ii) surface/s (iii) material to be used (optional) and

(iv) free text notes. The recordings of the above should then be related to the treatment planand treatment notes (COHS 2007).

Treatment notes Treatment notes (progress notes) are the recording of any discussions taking place during an appointment and the details of treatment provided as identified in the treatment plan. The notes can be entered by the treating clinician or by other clinicians and staff, but must besigned off by the treating clinician. Treatment notes can be extensive and they should include: (i) item number, tooth number and tooth surface (ii) Australian Dental Association Inc (ADA)item number (iii) surface/s restored (iv) material/s used (v) images taken (vi) prosthetic appliancesfitted (both fixed and removable) including full and partial dentures, crowns, bridges andimplants (Qld Health 2003).

Medical history Medical history is based on a series of questions identifying the health status of the clientthrough positive and negative responses (NSW Health 2007), and supplementary notes asrequired (COHS 2007).

Sign off Sign off is the work practice that indicates the clinical information gathering and treatmentprovided is true and correct. The work practices requiring a sign off are when: (i) charting on theodontograms and soft tissue diagrams (ii) taking of a medical history (iii) agreement of a treatmentplan that may or may not be prioritised (iv) completing treatment notes (v) requesting a referralletter/authority to a contracted private provider or in-house specialist (vi) scanning and/orattaching documents/images that are to be add to the client's OHR (vii) recording sterilisationtracking requirements, and (viii) making amendments to any aspect of the EOHR (COHS 2007).

APPENDIX A

Definition of terms


System Yes No

Allergies (eg medication, latex) ■■ ■■

Rheumatic fever ■■ ■■

Heart murmur/defect/valve replacements ■■ ■■

Cardiovascular (eg pacemaker, bypass) ■■ ■■

Hypertension ■■ ■■

Haematology (eg bleeding problems) ■■ ■■

CNS (eg epilepsy, stroke, mental disorder, CJD) ■■ ■■

Respiratory (eg asthma, emphysema, TB) ■■ ■■

Gastrointestinal (eg ulcer) ■■ ■■

Endocrine system (eg diabetes, thyroid) ■■ ■■

Urinary system (eg kidney) ■■ ■■

System Yes No

Hepatic (eg liver or other) ■■ ■■

Musculoskeletal (eg arthritis, osteoporosis,joint replacements)

■■ ■■

Oncology (eg type, radiotherapy, chemotherapy) ■■ ■■

Infectious disease (eg hepatitis, HIV, multi resistant organisms)

■■ ■■

Immune system (eg transplant) ■■ ■■

Operations / hospitalisation ■■ ■■

Pregnancy ■■ ■■

Smoking ■■ ■■

Other conditions ■■ ■■

Medication (bisphosphonates therapy) ■■ ■■

Recreational drugs ■■ ■■

I hereby agree that the medical history provided is true and correct

Name Signature Date

Clinician’s name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Interpreter’s name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Aboriginal Liaison Officer’s name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Medication

Additionial information

Date ___________________________________________ Patient details or sticker

Medical alert____________________________________

________________________________________________

________________________________________________

Allergies________________________________________

________________________________________________

________________________________________________ Medical Practitioner _____________________________

APPENDIX B

Medical History (Example 1)


Medical History

Date Additional information Clinician Name Clinician signature

Medical Alert

Allergies

Patient details or sticker


Medical History (Example 2)

System Date Date Date Date

Allergies (eg medication, latex) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Rheumatic fever ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Heart murmur/defect/valve replacements ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Cardiovascular (eg pacemaker, bypass) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Hypertension ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Haematology (eg bleeding problems) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

CNS (eg epilepsy, stroke, mental disorder, CJD) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Respiratory (eg asthma, emphysema, TB) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Gastrointestinal (eg ulcer) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Endocrine System (eg diabetes, thyroid) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Urinary system (eg kidney) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Hepatic (eg liver or other) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Musculoskeletal (eg arthritis, osteoporosis, joint replacements) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Oncology (eg type, radiotherapy, chemotherapy) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Infectious disease (eg, hepatitis, HIV, multi resistant organisms) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Immune system (eg transplant) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Operations/hospitalisation ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Pregnancy ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Smoking ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Other conditions ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Medication (bisphosphonates therapy) ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Recreational drugs ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N ■■ Y ■■ N

Medical Alert

Allergies

Patient details or sticker

Medication Additional Information

Medical Practioner

I hereby agree that the medical history provided is true and correct

Name Signature Date

Clinician’s name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Interpreter’s name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Aboriginal Liaison Officer’s name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -


03 04 05

Primary 55 54 53 52 51 61 62 63 64 65 01 maxilla

Permanent 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

Permanent 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Primary 85 84 83 82 81 71 72 73 74 75 02 mandible

08 07 06

Root Surface Odontogram (Dennison, P. 1999)

APPENDIX C

Federation Dentaire Internationale (FDI)

2 Digit Code for Oral Cavity and dentition

Two digit codes for the jaws and sextants of the mouth are:

i) 00 indicates the mouth

ii) 01 indicates the maxilla

iii) 02 indicates the mandible

v) 10 to 40 indicate the quadrants in clockwise order starting on the top right.


Anterior Ant

Arrested Caries AC

Bilateral (ly) bilat

Buccal B

Cardiovascular System CVS

Caries Free CF

Cemento-enamel junction CEJ

Central Nervous System CNS

Centric Occlusion CO

Centric Relation CR Contextual note

Cephalometry / ic Ceph

Distal D

Diagnosis Dx

Drifting Tooth

AC

Anatomy

APPENDIX D

Terms, Abbreviations and Symbols

Charting notation Explanation Term Abbreviation (if required) (if required)


PAGE 14 NSW Oral Health Record Protocols NSW Health

Incisal I

Labial Lab

Lateral Lat

LeftL with circle

around it

Left Hand Side LHS

Lingual L

Lower Left LLLL – not to be used when

referring to teeth

Lower Right LRLR – not to be used when

referring to teeth

Mandible /Mandibular Md

Maxilla /Maxillary Mx Contextual note

Maxillo-Mandibular

Relationship / recordMMR

Mesial M

Mesial-occlusodistal MODSample of combination

for tooth surfaces

Missing tooth

Occlusal (on chart) O

Occlusion (notes) Occl



Occlusal Vertical Dimension OVD

On Examination O/E

Over Retained O/R

Overbite O/bite

Overjet O/jet

Palatal P

Partially erupted PE

Posterior Post

Quadrant Q

Quadrant, lower left Q3

Quadrant, lower right Q4

Quadrant, upper left Q2

Quadrant, upper right Q1

Secondary Caries 2oC

Retained Root RR

Retruded Position RP

PE

RR




RightR with circle

around it

Right Hand Side RHS

SoundRoot Surface Root Surface Odontogram

Odontogram

SupernumeryS with circle

around it

Temporo-mandibular joint TMJ

Unerupted UE

Upper Left UL

Upper Right UR

Vertical Dimension VD

Examination

Assessment Assess

Bite Wing radiograph/s

or film/sBW

Cerebro-Vascular Accident CVA

Chief Complaint CC

Cigarettes Cigs

Class Cl Contextual note

S

UE



Community Periodontal Index CPI

Complains (ing) of C/O

Consultation Consult

Decrease (d) (ing)

Dental History DH Contextual note

Differential Diagnosis DDx

Division Div

Emergency Emerg

Examination Exam

Extra-oral E/O

Family History FH

Family and Social History S/FH

Father F with circle

around it

Female

Fracture # Fractured tooth

– contextual note

Fractured root

#

#




General Dental Practitioner GDP

General Medical Practitioner GMP

History of Present Complaint HPC

Increase (d) (ing)

Intra-Oral I/O

Male

Medical History MH

Mother M with circle

around it

Motor Vehicle Accident MVA

No Abnormalities Detected NAD

Non Vital NV

On Examination O/E

Orthopantomograph OPG

Past Medical History PMH

Past and Present

Dental HistoryDH

Past and Present

Medical HistoryMH

NV

M



Periapical Film/s

or Radiograph/sPA

Prognosis Px

Provisional Diagnosis PDx

Social History SH

Tender to Percussion TTP

Toothache T/ache

Treatment Tx

Treatment Plan TP

Anaesthesia

Citanest Cit

Inferior Dental Block ID Block

Infiltration Infilt

Local Anaesthetic LA

Nitrous Oxide N2O

Relative Anaesthesia RA

Xylocaine Xylo




Endodontic

Cotton Pellet CP

Endodontic (s) Endo

Ferricsulphate FeS

Gutta Percha GP

Hydrogen Peroxide H2O2

Ledermix Led

Master Apical File MAF

Root Canal Therapy RCT

Root Filling Root filling required

Root filling present

Size ##

Working length WL



Oral surgery

Black Silk Suture BSS

Cat Gut Suture CGS

Extraction or Exodontia Exo Tooth to be extracted

Tooth extracted

Inter-maxillary Fixation IMF

Interrupted Cat Gut Suture ICGS

Oral and Maxillo Facial Surgery OMFS

Oral Surgery OS

Removal of sutures ROS

Surgical removal SR

Orthodontic

Cross bite X-bite

Full Fixed Orthodontic

ApplianceFFA

Index of Orthodontic

Treatment NeedsIOTN

Mandibular Anterior

CrowdingLAC Lower




Mandibular Removable

Orthodontic ApplianceLRA

Maxillary Anterior Crowding UAC Upper

Maxillary Removable

Orthodontic ApplianceURA

Orthodontics Ortho

Rapid Maxillary Expansion RME

Paediatric

Paediatric dentistry Paedo

Pulpectomy Pulpect

Pulpotomy Pulpot

Stainless Steel SS

Stainless Steel Crown SSC

To be left TBL

Periodontic

Acute Necrotising

Ulcerative GingivitisANUG

Bleeding on Probing BOP

Hand Scale H/Scale



FS

FS

F

F


Loss of Attachment LOA

Mucogingival junction MGJ

Periodontics Perio

Root Planing RP Contextual comment

Subgingival Subging

Supragingival Supraging

Preventive

Acidulated phosphate fluoride APF

Fissure Sealant FS Fissure Sealant required

Fissure Sealant present

Fluoride F Fluoride application required

Fluoride application given

Mouthguard M/guard

Oral Health Promotion OHP

Oral Hygiene OH

Oral Hygiene Instruction OHI



Preventive Prev

Preventive Resin Restoration PRR

Prophylaxis Prophy

Scale & Clean S+C

Sodium Fluoride NaF

Stannous Fluoride SnF2

Toothbrushing Instruction TBI

Prosthetics fixed

Acrylic Jacket Crown AJC

Crown Crown required

Crown present

(insert other examples)

Crown and Bridge C+B Crown and bridge required

Crown and bridge present

Full Gold Crown FGC

Implant ipx

Metallo-ceramic restoration/

metal ceramic crownMCC



Porcelain Jacket Crown PJC

Post core P/core

Prosthetics removable

Addition Add

Chrome Cobalt CrCo

Full Denture, Mandibular only -/F

Full Denture, Mandibular

and MaxillaryF/F

Full Denture, Maxillary only F/-

Immediate Denture Immed

Partial Denture, Mandibular

only -/P

Partial Denture, Mandibular

and Maxillary P/P

Partial Denture, Maxillary only P/-

Primary Impression 1o Imp

Prosthetic Pros

Secondary Impression 2o Imp




Restorative

Amalgam Amal Black solid fill

Calcium Hydroxide Ca(OH)2

Class Cl

Composite Resin CR

Glass Ionomer Cement GIC

Interim Restoration Temp

Intermediate restorative

materialIRM

O/hang ø/hang

Resin Modified Glass Ionomer RMGI

Restoration required – outline Restoration Rest entire surface where lesion is

identified (eg is two surfaces)

Amalgam – solid

Acrylic – diagonal

Gold – vertical

Vitrebond Vbond

Zinc Oxide Eugenol ZOE

Restoration present outline

whole of surface and then

etch for material used

(eg is two surfaces)

oh



Zinc Phosphate ZnPO4

Other

Adjustment Adj

Alginate Alg

Biopsy Bx

Carbon Dioxide CO2

Chlorhexidine CHx

Impression Imp

Issue Iss

Management Mx Contextual note

Not Caries Free NCF

Post-operative (ly) Post-op

Post Operative

Instructions givenPOIG

Pre-operative Pre-op

Prescribe Rx

Rubber Dam RDam




Advise Adv

Appointment Appt

Date of Birth DOB

Dental Assistant DA Contextual note

Dental Hygienist DH Contextual note

Dental Officer DO Contextual note

Dental Prosthetists DP Contextual note

Dental Therapist DT Contextual note

Fail to attend FTA

Further appointment made FAM

Information System

for Oral Health ISOH

New Patient N/P

Next Visit N/V

Patient Pt

Primary Oral Care POC

Priority Oral Health Program POHP



Recall R/C

Refer Ref

Relief of Pain ROP

Required Req

Reviewed Rev

School Assessment Program SAP

Unable to attend UTA

Visiting Dental Officer VDO

Waiting list W/L


SHP: (PH) 060017

oral health record protocols - nsw · in such areas of odontogram, charting techniques and...

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