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Improving the Preoperative Recording of Patient Dental State by Anaesthetists

Central Coast Local Health District
Project Added:
23 September 2016
Last updated:
3 November 2016

Improving the Preoperative Recording of Patient Dental State by Anaesthetists


Central Coast Local Health District (CCLHD) designed a new anaesthesia form, produced educational posters for staff and developed a dental package that encouraged anaesthetists to document the dental state of patients prior to surgery.


To increase the rate of anaesthesia forms at Gosford and Wyong Hospitals that include a record of the patient’s preoperative dental state, to 99% within nine months.  


  • Reduces the risk of dental claims for damage during surgery, in people whose teeth have a pre-existing defect or are considered at risk and have been warned of that risk.
  • Improves the protection of the patient’s teeth during surgery.
  • Improves the accuracy of preoperative documentation.
  • Reduces the costs associated with dental claims.


Preoperative anaesthesia forms are required for all patients undergoing surgery. It allows anaesthetists to document a plan and identify areas of concern or opportunities for health improvement. These forms include an area to document the dental state of the patient prior to surgery. If the dental state is not documented, the local health district may be liable for repairing pre-existing dental trauma.

Prior to the project, there were a number of incidences where CCLHD was asked to pay for expensive dental repairs that patients claimed were a result of the surgery. On examination of their preoperative anaesthesia forms, no dental state was recorded. However, the anaesthetists responsible for these patients claimed the patients’ dental state was ‘terrible’ prior to their surgery. In response to these results, an audit was undertaken in June 2015, which showed 64% compliance in documenting the preoperative dental state of patients.

It was anticipated that increasing compliance with this documentation and ensuring patients are warned of the risks to their teeth will allow CCLHD to demonstrate due care. As a result, it will not be liable for repairing dental trauma that was present before the patients’ surgery.


  • An audit was conducted of all surgical patients at Gosford and Wyong Hospitals in June 2015, to determine how often the dental state was recorded on anaesthesia forms.
  • An announcement was made at the December 2015 Anaesthesia Department meeting, to acknowledge the focus on patients’ dental state.
  • A new anaesthesia form was designed, with a larger highlighted area to document the dental state of patients.
  • Posters were designed and placed in anaesthesia bays, to remind staff to complete the anaesthesia form in full and educate them on the risks of not doing so.
  • The performance of the group was collected in March 2016, with mentoring for individuals who had low compliance rates with recording the dental state of patients prior to surgery.
  • A dental package was compiled for anaesthetists, so they could provide accurate information to patients whose teeth had been damaged before, during or after surgery. It included forms and agreed advice on what to tell patients if damage occurs.

Project status

Sustained - the initiative has been implemented and is sustained in standard business.

Key dates

August 2015 to June 2016.

Implementation sites

  • Gosford Hospital, CCLHD
  • Wyong Hospital, CCLHD



Monthly audits of anaesthesia forms for surgical patients at Gosford and Wyong Hospitals were conducted between August 2015 and May 2016. Results showed less than 80% compliance in the first five months, prior to implementation of the project. Between January and May 2016, it increased to a consistent 85%. The project team will continue to improve results through additional solutions, including mandatory reporting fields in electronic records.

Graph showing steady increase in records with dental documentation

Lessons learnt

  • The introduction of the dental package was seen in a positive light by anaesthetists, which was an unexpected win for the project. It took significant negotiations between managers to form appropriate responses, but is now a valuable resource that can be easily distributed to other local health districts.
  • One person’s performance can destroy a good result, so management of individuals as well as a group is important.
  • Not everyone likes change or challenges, however most people try to improve when shown why change is necessary.

Further reading


Scott Fortey
Head of Department
Anaesthesia Department
Central Coast Local Health District
Phone: 02 4320 2092

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