Abbreviations

Policy Directive
Department of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/
space space
Oral Health Record Protocols - NSW

space 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 standard for clinical record documentation by oral health clinicians and an information 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 Health Corporation, Board Governed Statutory Health Corporations, Dental Schools 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 of Health, Public Health Units, Tertiary Education Institutes Review date 05-May-2010 File No. H07/106015 Status Active
Director-General space This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for 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
Contents
Foreword ................................................................................................................ii 1. Introduction .......................................................................................................1

1.1 1.2 1.3 1.4 Purpose.........................................................................................................................1 Scope............................................................................................................................1 Application of Policy......................................................................................................1 Evaluation process.........................................................................................................2
2. Key elements .....................................................................................................3

2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 Patient identification .....................................................................................................3 Medical history..............................................................................................................3 Consent for treatment ..................................................................................................3 Emergency care.............................................................................................................3 Authorities ....................................................................................................................3 Examinations and treatment plan for a course of care...................................................3 Charting and tooth identification ..................................................................................4 Prevention.....................................................................................................................4 Anaesthetics..................................................................................................................4 Restorations ..................................................................................................................4 Exodontia......................................................................................................................4 Minor oral surgery.........................................................................................................4 Medication....................................................................................................................4 Sign off .........................................................................................................................5 Sterilisation tracking ......................................................................................................5 Data collection ..............................................................................................................5 Open disclosure.............................................................................................................5 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
NSW Oral Health Record Protocols NSW Health PAGE i
Foreword
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
PAGE ii NSW Oral Health Record Protocols NSW Health
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
1.3
Application of Policy
What 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.
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
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)
The scope of OHR is to:

I
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 PAGE 1
Who does this apply to? The policy directive is to assist:

I I I I I I I I I I I I
I I I I I I I I I I I
charting and tooth identification prevention anaesthetics restorations exodontia minor oral surgery medication sign off sterilisation tracking data collection generic abbreviations
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.
Definition of terms The definition of terms (Appendix A) provides an explanation of OHR (paper and electronic) work practices (COHS 2007).
1.4
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:
I I I I I I
Evaluation process
patient identification medical history consent to treatment emergency care authorities examinations and treatment plan for a course of care
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 1 of Healthcare Standards Clinical Indicator Users Manual 2007, Oral Health Indicator Area 3, 1 Patient Record Audits (ACHS 2007) or similar.
http://www.achs.org.au
PAGE 2 NSW Oral Health Record Protocols NSW Health
SECTION 2
Key elements
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.
2.3
Consent for treatment
2.1
Patient Identification
Patient identification by the treating clinician needs to be in compliance with NSW Health Patient Identification Correct Patient, Correct Procedure 2 and Correct Site Model Policy .
2.2
Obtaining consent for treatment needs to be in compliance with the NSW Health 'Consent to Medical 3 Treatment Patient Information , and NSW Multiingual Health Resources by AHS, DOH and NGOs funded by 4 NSW Health (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
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.
Authorities
The recording of the provision of an authority is governed under the Oral Health Fee for Service Scheme.
2.6
Examinations and treatment plan for 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 3 4
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf http://www.health.nsw.gov.au/policies/GL/2005/pdf/PD2005_032.pdf

2.7
Charting and tooth identification
2.10
Restorations
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
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
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
d) An indication if post operative instructions were given.

2.13
Medication
Anaesthetics
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.
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.
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_008.pdf
2.14
Sign off
2.16
Data collection
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
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 9 identified in 'Open Disclosure' and GL 2007_007 10 Open Disclosure Guidelines.
2.18
Sterilisation tracking
Abbreviations
Recording of sterilisation process are to be in accordance with NSW Health 'Oral Health Infection Control Guidelines for Oral Health Care Settings'6 7 and Infection Control Policy.
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.
http://www.health.nsw.gov.au/policies/GL/2005/pdf/GL2005_037.pdf http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf 8 http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_291.pdf 9 http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_040.pdf 10 http://www.health.nsw.gov.au/policies/gl/2005/pdf/GL2007_007.pdf

6 7
SECTION 3
Acronyms
CAG COHS GL NSW OHR PD SOHE
Clinical Advisory Group Centre for Oral Health Strategy NSW Guideline New South Wales Oral Health Record Policy directive State Oral Health Executive
SECTION 4
References
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 Users 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
APPENDIX A
Definition of terms
Term
Referral pathway
Definition
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 an examination, and record that aspect of the client's management pertinent to the area/s (COHS 2007). The treating clinician is the person responsible for delivering a treatment or procedure. These work practices 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 in radiography and oral health education (iii) allied health professionals such as Physiotherapists and Occupational Therapists and (iv) Radiographers and Registered Nurses (COHS 2007). An oral examination includes the examination of both soft and hard tissues, and findings are recorded using an odontogram and/or text. The charting needs to comply with the World Dental Federation (FDI) system and should include: (i) restored teeth (tooth code, surface/s involved and materials used) (ii) sound and unrestored teeth (iii) missing teeth (iv) hard tissue and soft tissue abnormalities (v) occlusion, including tooth mobility (vi) periodontal status including periodontal pocket depth, supra-gingival calculus, sub-gingival calculus and oral hygiene status and type of prosthetic appliances present (COHS 2007). Consent for treatment is a legal requirement which must be obtained prior to commencing 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 they understand the (i) diagnosis (ii) proposed treatment and benefits (treatment plan) (iii) risks regarding 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 Treatment plan is the recording of subsequent prioritised treatments with textual 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 plan and treatment notes (COHS 2007). 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 be signed 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 appliances fitted (both fixed and removable) including full and partial dentures, crowns, bridges and implants (Qld Health 2003). Medical history is based on a series of questions identifying the health status of the client through positive and negative responses (NSW Health 2007), and supplementary notes as required (COHS 2007). Sign off is the work practice that indicates the clinical information gathering and treatment provided is true and correct. The work practices requiring a sign off are when: (i) charting on the odontograms and soft tissue diagrams (ii) taking of a medical history (iii) agreement of a treatment plan that may or may not be prioritised (iv) completing treatment notes (v) requesting a referral letter/authority to a contracted private provider or in-house specialist (vi) scanning and/or attaching documents/images that are to be add to the client's OHR (vii) recording sterilisation tracking requirements, and (viii) making amendments to any aspect of the EOHR (COHS 2007).
Treating clinician
Oral examination
Consent for treatment
Prioritised treatment plan
Treatment notes
Medical history
Sign off
APPENDIX B
Medical History (Example 1)
Date ___________________________________________ Medical alert____________________________________ ________________________________________________ ________________________________________________ Allergies________________________________________ ________________________________________________ ________________________________________________
Patient details or sticker
Medical Practitioner _____________________________
System 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)
Yes No I I I I I I I I I I I I I I I I I
System Hepatic (eg liver or other) Musculoskeletal (eg arthritis, osteoporosis,

joint replacements)
Yes No I I I I I I I I I I I I I
Oncology (eg type, radiotherapy, chemotherapy) I Infectious disease (eg hepatitis, HIV, multi resistant organisms) Immune system (eg transplant) Operations / hospitalisation I I I I I I I I
I I I I I
Pregnancy Smoking Other conditions Medication (bisphosphonates therapy) Recreational drugs
Medication
Additionial information
I hereby agree that the medical history provided is true and correct Name Signature Date
Clinicians name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Interpreters name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Aboriginal Liaison Officers name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - NSW Oral Health Record Protocols NSW Health PAGE 9
Medical History
Medical Alert Patient details or sticker
Allergies
Date
Additional information
Clinician Name
Clinician signature
Medical History (Example 2)

Medical Alert Patient details or sticker
Allergies
System 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) 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 Medication
Date IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN IY IN
Additional Information
Medical Practioner
I hereby agree that the medical history provided is true and correct Name Signature Date
Clinicians name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Interpreters name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Aboriginal Liaison Officers name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - NSW Oral Health Record Protocols NSW Health PAGE 11
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.
03 Primary Permanent Permanent Primary
04
05 01 maxilla
55 54 53 52 51 61 62 63 64 65 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 85 84 83 82 81 71 72 73 74 75 08 07 06
02 mandible
Root Surface Odontogram (Dennison, P. 1999)
APPENDIX D
Terms, Abbreviations and Symbols
Term Anatomy
Abbreviation
Charting notation (if required)
Explanation (if required)
Anterior
Ant
AC
Arrested Caries AC
Bilateral (ly)
bilat
Buccal
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
Diagnosis
Dx
Drifting Tooth
Term Incisal
Abbreviation I
Labial
Lab
Lateral
Lat L with circle around it
Left
Left Hand Side
LHS
Lingual
L LL not to be used when referring to teeth LR not to be used when referring to teeth
Lower Left
LL
Lower Right
LR
Mandible / Mandibular
Md
Maxilla / Maxillary
Mx
Contextual note
Maxillo-Mandibular Relationship / record
MMR
Mesial
M Sample of combination for tooth surfaces
Mesial-occlusodistal
MOD
Missing tooth
Occlusal (on chart)
Occlusion (notes)
Occl
Term Occlusal Vertical Dimension
Abbreviation OVD
On Examination
O/E
Over Retained
O/R
Overbite
O/bite
Overjet
O/jet
Palatal
PE
Partially erupted PE
Posterior
Post
Quadrant
Quadrant, lower left
Q3
Quadrant, lower right
Q4
Quadrant, upper left
Q2
Quadrant, upper right
Q1
Secondary Caries
2oC
RR
Retained Root RR
Retruded Position
RP
Term Right
Abbreviation
Explanation (if required) R with circle around it
Right Hand Side
RHS Root Surface Odontogram S with circle around it Root Surface Odontogram
Sound
Supernumery
S
UE
Temporo-mandibular joint
TMJ
Unerupted
UE
Upper Left
UL
Upper Right
UR
Vertical Dimension
VD
Examination
Assessment Bite Wing radiograph /s or film / s
Assess
BW
Cerebro-Vascular Accident
CVA
Chief Complaint
CC
Cigarettes
Cigs
Class
Cl
Contextual note
Term Community Periodontal Index
Abbreviation 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 F with circle around it
Father
Female
#
Fracture #
Fractured tooth contextual note Fractured root
Term General Dental Practitioner
Abbreviation GDP
General Medical Practitioner
GMP
History of Present Complaint
HPC
Increase (d) (ing)
Intra-Oral
I/O
Male
Medical History
MH M with circle around it
Mother
Motor Vehicle Accident
MVA
No Abnormalities Detected
NAD
NV
Non Vital NV
On Examination
O/E
Orthopantomograph
OPG
Past Medical History Past and Present Dental History Past and Present Medical History
PMH
DH
MH
Term Periapical Film/s or Radiograph/s
Abbreviation PA
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
Term
Abbreviation
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
Term
Abbreviation
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 Full Fixed Orthodontic Appliance Index of Orthodontic Treatment Needs Mandibular Anterior Crowding
X-bite
FFA
IOTN
LAC
Lower
Term Mandibular Removable Orthodontic Appliance
Abbreviation LRA
Maxillary Anterior Crowding Maxillary Removable Orthodontic Appliance
UAC
Upper
URA
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 Gingivitis ANUG
Bleeding on Probing
BOP
Hand Scale
H/Scale
Term Loss of Attachment
Abbreviation LOA
Mucogingival junction
MGJ
Periodontics
Perio
Root Planing
RP
Contextual comment
Subgingival
Subging
Supragingival
Supraging
Preventive
Acidulated phosphate fluoride
APF
FS
Fissure Sealant FS Fissure Sealant required
FS
Fissure Sealant present
F
Fluoride F Fluoride application required
Fluoride application given
Mouthguard
M/guard
Oral Health Promotion
OHP
Oral Hygiene
OH
Oral Hygiene Instruction
OHI
Term Preventive
Abbreviation 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 Metallo-ceramic restoration / metal ceramic crown
ipx
MCC
Term Porcelain Jacket Crown
Abbreviation PJC
Post core
P/core
Prosthetics removable
Addition
Add
Chrome Cobalt
CrCo
Full Denture, Mandibular only Full Denture, Mandibular and Maxillary
-/F
F/F
Full Denture, Maxillary only
F/-
Immediate Denture Partial Denture, Mandibular only Partial Denture, Mandibular and Maxillary
Immed
-/P
P/P
Partial Denture, Maxillary only
P/-
Primary Impression
1o Imp
Prosthetic
Pros
Secondary Impression
2o Imp
Term
Abbreviation
Restorative
Amalgam
Amal
Black solid fill
Calcium Hydroxide
Ca(OH)2
Class
Cl
Composite Resin
CR
Glass Ionomer Cement
GIC
Interim Restoration Intermediate restorative material
Temp
IRM
oh
O/hang /hang
Resin Modified Glass Ionomer
RMGI Restoration required outline entire surface where lesion is identified (eg is two surfaces)
Restoration
Rest
Amalgam solid Restoration present outline whole of surface and then etch for material used (eg is two surfaces)
Acrylic diagonal
Gold vertical
Vitrebond
Vbond
Zinc Oxide Eugenol
ZOE
Term Zinc Phosphate
Abbreviation 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 Operative Instructions given
Post-op
POIG
Pre-operative
Pre-op
Prescribe
Rx
Rubber Dam
RDam
Term Advise
Abbreviation 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 Information System for Oral Health
FAM
ISOH
New Patient
N/P
Next Visit
N/V
Patient
Pt
Primary Oral Care
POC
Priority Oral Health Program
POHP
Term Recall
Abbreviation 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

Abbreviations

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Policy Directive

Oral Health Record Protocols - NSW

NSW Oral Health Record Protocols

Foreword ................................................................................................................ii 1. Introduction .......................................................................................................1

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

3. Acronyms............................................................................................................6 4. References ..........................................................................................................7

NSW Oral Health Record Protocols NSW Health PAGE i

PAGE ii NSW Oral Health Record Protocols NSW Health

The scope of OHR is to:

NSW Oral Health Record Protocols NSW Health PAGE 1

Who does this apply to? The policy directive is to assist:

PAGE 2 NSW Oral Health Record Protocols NSW Health

Consent for treatment

Examinations and treatment plan for a course of care

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

Charting and tooth identification

Minor oral surgery

d) An indication if post operative instructions were given.

PAGE 4 NSW Oral Health Record Protocols NSW Health

NSW Oral Health Record Protocols NSW Health PAGE 5

CAG COHS GL NSW OHR PD SOHE

PAGE 6 NSW Oral Health Record Protocols NSW Health

NSW Oral Health Record Protocols NSW Health PAGE 7

Consent for treatment

Prioritised treatment plan

PAGE 8 NSW Oral Health Record Protocols NSW Health

Medical History (Example 1)

Patient details or sticker

Medical Practitioner _____________________________

System Hepatic (eg liver or other) Musculoskeletal (eg arthritis, osteoporosis,

Pregnancy Smoking Other conditions Medication (bisphosphonates therapy) Recreational drugs

PAGE 10 NSW Oral Health Record Protocols NSW Health

Medical History (Example 2)

Federation Dentaire Internationale (FDI)

2 Digit Code for Oral Cavity and dentition

03 Primary Permanent Permanent Primary

Root Surface Odontogram (Dennison, P. 1999)

PAGE 12 NSW Oral Health Record Protocols NSW Health

Terms, Abbreviations and Symbols

Charting notation (if required)

Explanation (if required)

Central Nervous System

NSW Oral Health Record Protocols NSW Health PAGE 13

Charting notation (if required)

Explanation (if required)

Lat L with circle around it

Left Hand Side

Maxillo-Mandibular Relationship / record

M Sample of combination for tooth surfaces

Occlusal (on chart)

PAGE 14 NSW Oral Health Record Protocols NSW Health

Term Occlusal Vertical Dimension

Charting notation (if required)

Explanation (if required)

Quadrant, lower left

Quadrant, lower right

Quadrant, upper left

Quadrant, upper right

NSW Oral Health Record Protocols NSW Health PAGE 15

Charting notation (if required)

Explanation (if required) R with circle around it

Right Hand Side

Assessment Bite Wing radiograph /s or film / s