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Oral surgery is one of the most procedure-intensive and documentation-sensitive areas of dentistry. Every extraction, surgical removal, and implant placement must be fully documented: the anaesthetic given, the technique used, any complications, the post-operative instructions provided, and the follow-up plan. This page explains how to record oral surgery procedures from assessment through to post-operative review.

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Before You Start

  • Clinical Procedure Templates for each surgical procedure must be set up.
  • For sedation cases, the patient must have approved pre-surgical blood tests on file. See Laboratory.
  • Consent must be documented before the procedure begins.
  • You need the Healthcare Practitioner role to document surgical procedures.

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Setting Up Surgical Procedure Templates

Create a Clinical Procedure Template for each surgical procedure type:

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Step 1: Pre-Surgical Assessment

The pre-surgical assessment is documented as a Patient Encounter with the appointment type set to “Oral Surgery Consultation”. In the Patient Encounter, record: History:
  • Reason for referral or self-referral
  • Duration of the problem
  • Previous attempts at treatment
  • Dental anxiety level (relevant for sedation planning)
  • Medical history review (diabetes, anticoagulants, bisphosphonates, immunosuppression)
  • Bleeding history (excessive bleeding after previous procedures)
  • Medications that affect surgery (Warfarin, Apixaban, bisphosphonates, steroids)
Examination:
  • Tooth status (eruption, mobility, tenderness to percussion)
  • Soft tissue assessment (swelling, sinus, pus)
  • Mouth opening (normal, limited - if limited, affects access for lower wisdom teeth)
X-Ray Review: Order an OPG or IOPA if not already available. See Dental Radiography for how to document findings. For impacted wisdom teeth, the OPG must show:
  • Eruption status (soft tissue, partial, unerupted)
  • Angulation (mesioangular, distoangular, horizontal, vertical)
  • Relationship to inferior dental canal (for lower teeth)
  • Root morphology (fused, divergent, dilacerated)
  • Proximity to adjacent tooth
Consent Discussion: Record in the encounter notes that consent has been discussed and the following risks explained:
  • Pain and swelling post-operatively
  • Bruising
  • Dry socket (delayed healing after extraction)
  • Numbness (inferior alveolar nerve or lingual nerve injury - for lower wisdom teeth)
  • Sinus opening (for upper posterior extractions)
  • Damage to adjacent teeth
Attach the signed consent form to the Patient Encounter record.

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Step 2: Pre-Operative Nursing Checklist

On the day of surgery, the dental nurse completes a pre-operative checklist before the procedure begins:
  1. Go to Healthcare workspace → Nursing card → Nursing Task
  2. Complete the pre-operative tasks for the surgical patient:
Nursing Task pre-operative checklist for oral surgery showing all tasks listed with completion checkboxes and notes field

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Step 3: Recording Vital Signs

Before any surgical procedure and before sedation is administered:
  1. Go to Healthcare workspace → Consultation card → Vital Signs → New
  2. Link to the patient
  3. Record:

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Step 4: Performing and Documenting the Procedure

After the procedure is completed, the dentist completes the Clinical Procedure record:
  1. Open the Clinical Procedure record (created from the encounter or appointment)
  2. Record the procedure details in the Notes field:
For Simple Extraction:
For Surgical Extraction (e.g., Impacted Wisdom Tooth):
For Implant Placement:

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Step 5: Post-Operative Prescriptions

After surgical procedures, raise a prescription from the Patient Encounter:

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Step 6: Post-Operative Review

Book the post-operative review appointment before the patient leaves:
  • Simple extractions: usually no formal review needed unless patient has concerns
  • Surgical extractions and wisdom teeth: Day 7 for suture removal and healing check
  • Implant placement: Day 14 for suture removal, then 3-month review for osseointegration check
Document the review in a new Patient Encounter:

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Field Guide: Clinical Procedure (Surgical)

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Best Practices

  • Never extract a tooth without radiographic evidence of the root and surrounding bone, unless it is a clearly mobile, rootless primary tooth - underbones, extra roots, and proximity to adjacent structures are invisible clinically but visible radiographically
  • For lower wisdom teeth, always discuss the risk of inferior alveolar nerve injury before surgery, record the discussion in the notes, and obtain signed consent
  • For patients on bisphosphonates, document this clearly before any extraction and discuss medication-related osteonecrosis of the jaw (MRONJ) risk with the patient. Consider a specialist referral for patients on IV bisphosphonates
  • Always book the post-operative review before the patient leaves - patients who are in pain or have complications must be able to return promptly, and an unbooked follow-up is frequently missed
  • Record every incidence of post-operative complication (dry socket, nerve involvement, sinus opening) in the clinical record - complications that are managed promptly and documented properly rarely become complaints; complications that are hidden or undocumented become serious liability risks

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Troubleshooting

The pre-operative checklist cannot be completed because the blood test result has not been approved Contact the LabTest Approver urgently. Do not proceed with sedation until results are approved and in range. Document the delay and reschedule the patient if results are not available in time. The patient’s blood pressure is too high to proceed Record the blood pressure reading in Vital Signs. Do not proceed with elective extraction if systolic is persistently above 180 mmHg. Refer the patient to their GP for blood pressure management. Document the decision in the encounter notes. A tooth has been extracted but the patient is requesting the tooth back This is a patient rights matter. If your clinic policy permits, the extracted tooth can be given to the patient after appropriate handling. Document the request and the outcome in the procedure notes.