Post on 29-May-2018
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Status Rescinded
Rescinded By GL2015_017
Director-GeneralspaceThis Policy Directive may be varied, withdrawn or replaced at any time.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.
PAGE 2 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
NSW Oral Health Record Protocols NSW Health PAGE 3
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
PAGE 4 NSW Oral Health Record Protocols NSW Health
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
Clinical notes should indicate the following elements:
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
Clinical notes should indicate the following elements:
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
Clinical notes should indicate the following elements:
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
Clinical notes should indicate the following elements:
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
NSW Oral Health Record Protocols NSW Health PAGE 5
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
PAGE 6 NSW Oral Health Record Protocols NSW Health
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
NSW Oral Health Record Protocols NSW Health PAGE 7
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
PAGE 8 NSW Oral Health Record Protocols NSW Health
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
NSW Oral Health Record Protocols NSW Health PAGE 9
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)
PAGE 10 NSW Oral Health Record Protocols NSW Health
Medical History
Date Additional information Clinician Name Clinician signature
Medical Alert
Allergies
Patient details or sticker
NSW Oral Health Record Protocols NSW Health PAGE 11
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 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PAGE 12 NSW Oral Health Record Protocols NSW Health
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.
NSW Oral Health Record Protocols NSW Health PAGE 13
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)
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
Charting notation Explanation Term Abbreviation (if required) (if required)
NSW Oral Health Record Protocols NSW Health PAGE 15
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
NSW Oral Health Record Protocols NSW Health PAGE 15
Charting notation Explanation Term Abbreviation (if required) (if required)
PAGE 16 NSW Oral Health Record Protocols NSW Health
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
Charting notation Explanation Term Abbreviation (if required) (if required)
NSW Oral Health Record Protocols NSW Health PAGE 17
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
#
#
NSW Oral Health Record Protocols NSW Health PAGE 17
Charting notation Explanation Term Abbreviation (if required) (if required)
PAGE 18 NSW Oral Health Record Protocols NSW Health
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
Charting notation Explanation Term Abbreviation (if required) (if required)
NSW Oral Health Record Protocols NSW Health PAGE 19
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
NSW Oral Health Record Protocols NSW Health PAGE 19
Charting notation Explanation Term Abbreviation (if required) (if required)
PAGE 20 NSW Oral Health Record Protocols NSW Health
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
Charting notation Explanation Term Abbreviation (if required) (if required)
NSW Oral Health Record Protocols NSW Health PAGE 21
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
NSW Oral Health Record Protocols NSW Health PAGE 21
Charting notation Explanation Term Abbreviation (if required) (if required)
PAGE 22 NSW Oral Health Record Protocols NSW Health
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
Charting notation Explanation Term Abbreviation (if required) (if required)
NSW Oral Health Record Protocols NSW Health PAGE 23
FS
FS
F
F
NSW Oral Health Record Protocols NSW Health PAGE 23
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
Charting notation Explanation Term Abbreviation (if required) (if required)
PAGE 24 NSW Oral Health Record Protocols NSW Health
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
Charting notation Explanation Term Abbreviation (if required) (if required)
NSW Oral Health Record Protocols NSW Health PAGE 25
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
NSW Oral Health Record Protocols NSW Health PAGE 25
Charting notation Explanation Term Abbreviation (if required) (if required)
PAGE 26 NSW Oral Health Record Protocols NSW Health
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
Charting notation Explanation Term Abbreviation (if required) (if required)
NSW Oral Health Record Protocols NSW Health PAGE 27
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
NSW Oral Health Record Protocols NSW Health PAGE 27
Charting notation Explanation Term Abbreviation (if required) (if required)
PAGE 28 NSW Oral Health Record Protocols NSW Health
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
Charting notation Explanation Term Abbreviation (if required) (if required)
NSW Oral Health Record Protocols NSW Health PAGE 29
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
NSW Oral Health Record Protocols NSW Health PAGE 29
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