Policy Directive

Ministry 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/

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Oral Health Record Protocols - NSW

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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, 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Status Rescinded
Rescinded By GL2015_017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-General
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This Policy Directive may be varied, withdrawn or replaced at any time.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.
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 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

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 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 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.
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? ■ charting and tooth identification
The policy directive is to assist: ■ prevention
■ Dental Specialists ■ anaesthetics
■ Dental Officers ■ restorations
■ Dental Therapists ■ exodontia
■ Dental Prosthetists ■ minor oral surgery
■ Dental Technicians ■ medication
■ Dental Assistants ■ sign off
■ Dental Hygienists ■ sterilisation tracking
■ Oral Health Therapists ■ data collection
■ Bachelor Oral Health students ■ generic abbreviations
■ Bachelor of Dentistry students Definition of terms
■ Dental Assistant Traineeship The definition of terms (Appendix A) provides an
■ Scholarship students. explanation of OHR (paper and electronic) work
practices (COHS 2007).
OHR key elements
The adoption of the OHR by Area Health Services must
1.4 Evaluation process
include the key elements identified in this document.
The key elements are as follows: The evaluation process for this policy directive is
through SOHE. The evaluation review is to be on a
■ patient identification
biyearly cycle or as identified by Department of Health.
■ medical history
Area Health Services are an accredited organisation
■ consent to treatment
and therefore it is recommended that the
■ emergency care implementation of this policy be reviewed through
■ authorities this quality process such as The Australian Council
1

■ examinations and treatment plan for a of Healthcare Standards Clinical Indicator Users
course of care Manual 2007, Oral Health Indicator Area 3,
1
Patient Record Audits (ACHS 2007) or similar.

1
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.
2.1 Patient Identification
2.3 Consent for treatment
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

Patient identification by the treating clinician needs NSW Health (guidelines for Production).
to be in compliance with NSW Health Patient
Identification – Correct Patient, Correct Procedure
2
2.4 Emergency care
and Correct Site Model Policy .
Clinical notes should indicate the following elements.
a) Chief complaint/reason for attendance
2.2 Medical History
b) Diagnostic data
The patient dental record should document a medical
c) Radiographs taken
history as taken by the clinician. Appendix B examples
1 and 2 provide medical history templates. d) Results of tests
e) Clinical findings
A medical history should include the following
elements: f) Management plan or treatment given .

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.
2.5 Authorities
The recording of the provision of an authority is
governed under the Oral Health Fee for Service
Scheme.
2.6 Examinations and treatment 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
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
3
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
4
http://www.health.nsw.gov.au/policies/GL/2005/pdf/PD2005_032.pdf

NSW Oral Health Record Protocols NSW Health PAGE 3

2.7 Charting and tooth identification 2.10 Restorations
In Appendix C the Federation Dentaire Internationale Clinical notes should indicate the following elements:
(FDI) notation for recording tooth number is to be used. a) Tooth involved
a) The odoontogram for permanent teeth should b) Surface/s involved
have root surfaces. A deciduous odontogram
c) Base/linings used
should be available where applicable. The outline
of the odontogram should be a colour that d) Restoration material and shades used
contrasts with black ink. e) Unusual depth or other features.
b) A standard set of charting symbols for the
recording of dentition is to be used. 2.11 Exodontia
c) In charting, the materials used in restorations
Clinical notes should indicate the following elements:
should be indicated as follows:
a) The tooth extracted
i. Amalgam is solid filled and black
b) Reasons for extraction
ii. Gold is vertical striping
c) Any complications
iii. Tooth coloured restoration is diagonal
striping from lower left to upper right d) An indication if post operative instructions
d) Periodontal charting: were given

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.
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

PAGE 4 NSW Oral Health Record Protocols NSW Health

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
7
and Infection Control Policy.
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
9
identified in 'Open Disclosure' and GL 2007_007
10
Open Disclosure Guidelines.
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.pdf
7
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

NSW Oral Health Record Protocols NSW Health PAGE 5

SECTION 3

Acronyms

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

PAGE 6 NSW Oral Health Record Protocols NSW Health

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 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
NSW Oral Health Record Protocols NSW Health PAGE 7
APPENDIX A

Definition of terms

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 an
examination, 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 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).

Oral examination 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 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 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 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 plan
and 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 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 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 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).

PAGE 8 NSW Oral Health Record Protocols NSW Health

APPENDIX B

Medical History (Example 1)

Date ___________________________________________ Patient details or sticker

Medical alert____________________________________

________________________________________________

________________________________________________

Allergies________________________________________

________________________________________________

________________________________________________ Medical Practitioner _____________________________

System Yes No System Yes No

Allergies (eg medication, latex) ■ ■ Hepatic (eg liver or other) ■ ■

Rheumatic fever ■ ■ Musculoskeletal (eg arthritis, osteoporosis,

■ ■
joint replacements)
Heart murmur / defect / valve replacements ■ ■
Oncology (eg type, radiotherapy, chemotherapy) ■ ■
Cardiovascular (eg pacemaker, bypass) ■ ■
Infectious disease (eg hepatitis, HIV,
■ ■
multi resistant organisms)
Hypertension ■ ■
Immune system (eg transplant) ■ ■
Haematology (eg bleeding problems) ■ ■
Operations / hospitalisation ■ ■
CNS (eg epilepsy, stroke, mental disorder, CJD) ■ ■
Pregnancy ■ ■
Respiratory (eg asthma, emphysema, TB) ■ ■
Smoking ■ ■
Gastrointestinal (eg ulcer) ■ ■ Other conditions ■ ■

Endocrine system (eg diabetes, thyroid) ■ ■ Medication (bisphosphonates therapy) ■ ■

Urinary system (eg kidney) ■ ■ Recreational drugs ■ ■

Medication

Additionial information

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 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

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

PAGE 10 NSW Oral Health Record Protocols NSW Health

Medical History (Example 2)
Medical Alert Patient details or sticker

Allergies

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

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 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

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 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)

PAGE 12 NSW Oral Health Record Protocols NSW Health

APPENDIX D

Terms, Abbreviations and Symbols

Charting notation Explanation

Term Abbreviation (if required) (if required)

Anatomy

Anterior Ant

AC
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

NSW Oral Health Record Protocols NSW Health PAGE 13

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

Incisal I

Labial Lab

Lateral Lat

L with circle
Left
around it

Left Hand Side LHS

Lingual L

LL – not to be used when

Lower Left LL
referring to teeth

LR – not to be used when

Lower Right LR
referring to teeth

Mandible / Mandibular Md

Maxilla / Maxillary Mx Contextual note

Maxillo-Mandibular
MMR
Relationship / record

Mesial M

Sample of combination
Mesial-occlusodistal MOD
for tooth surfaces

Missing tooth

Occlusal (on chart) O

Occlusion (notes) Occl

PAGE 14 NSW Oral Health Record Protocols NSW Health

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

Occlusal Vertical Dimension OVD

On Examination O/E

Over Retained O/R

Overbite O/bite

Overjet O/jet

Palatal P

PE
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

RR
Retained Root RR

Retruded Position RP

NSW Oral Health Record Protocols NSW Health PAGE 15

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

R with circle
Right
around it

Right Hand Side RHS

Root Surface Root Surface Odontogram

Sound
Odontogram

S with circle
Supernumery
around it S
Temporo-mandibular joint TMJ

UE
Unerupted UE

Upper Left UL

Upper Right UR

Vertical Dimension VD

Examination

Assessment Assess

Bite Wing radiograph /s

BW
or film / s

Cerebro-Vascular Accident CVA

Chief Complaint CC

Cigarettes Cigs

Class Cl Contextual note

PAGE 16 NSW Oral Health Record Protocols NSW Health

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

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

F with circle
Father
around it

Female

#
Fractured tooth
Fracture #
– contextual note

#
Fractured root

NSW Oral Health Record Protocols NSW Health PAGE 17

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

General Dental Practitioner GDP

General Medical Practitioner GMP

History of Present Complaint HPC

Increase (d) (ing)

Intra-Oral I/O

Male

Medical History MH

M with circle
Mother
around it
M

Motor Vehicle Accident MVA

No Abnormalities Detected NAD

NV
Non Vital NV

On Examination O/E

Orthopantomograph OPG

Past Medical History PMH

Past and Present

DH
Dental History

Past and Present

MH
Medical History

PAGE 18 NSW Oral Health Record Protocols NSW Health

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

Periapical Film/s
PA
or Radiograph/s

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)

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

PAGE 20 NSW Oral Health Record Protocols NSW Health

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

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

FFA
Appliance

Index of Orthodontic
IOTN
Treatment Needs

Mandibular Anterior
LAC Lower
Crowding

NSW Oral Health Record Protocols NSW Health PAGE 21

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

Mandibular Removable
LRA
Orthodontic Appliance

Maxillary Anterior Crowding UAC Upper

Maxillary Removable
URA
Orthodontic Appliance

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
ANUG
Ulcerative Gingivitis

Bleeding on Probing BOP

Hand Scale H/Scale

PAGE 22 NSW Oral Health Record Protocols NSW Health

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

Loss of Attachment 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

F
Fluoride application given

Mouthguard M/guard

Oral Health Promotion OHP

Oral Hygiene OH

Oral Hygiene Instruction OHI

NSW Oral Health Record Protocols NSW Health PAGE 23

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

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 /
MCC
metal ceramic crown

PAGE 24 NSW Oral Health Record Protocols NSW Health

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

Porcelain Jacket Crown PJC

Post core P/core

Prosthetics removable

Addition Add

Chrome Cobalt CrCo

Full Denture, Mandibular only -/F

Full Denture, Mandibular

F/F
and Maxillary

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)

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
IRM
material

oh
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
Restoration present outline
whole of surface and then
Acrylic – diagonal etch for material used
(eg is two surfaces)

Gold – vertical

Vitrebond Vbond

Zinc Oxide Eugenol ZOE

PAGE 26 NSW Oral Health Record Protocols NSW Health

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

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
POIG
Instructions given

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)

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
ISOH
for Oral Health

New Patient N/P

Next Visit N/V

Patient Pt

Primary Oral Care POC

Priority Oral Health Program POHP

PAGE 28 NSW Oral Health Record Protocols NSW Health

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

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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