<html><body><table><tr><td rowspan="2">ORAL HEALTH CENTRE OF WESTERN AUSTRALIA</td><td rowspan="2" style="text-align:center; vertical-align:middle;">Form 23 Patient Management Plan</td><td rowspan="2" style="text-align:left;">Use Patient Barcode Label Given Name: ______________________ Surname: ______________________ DOB: ______________________ TEMP: ______________________</td></tr><tr><td></td></tr><tr><td>Clinician:</td><td>Clinician ID:</td><td>Date:</td></tr><tr><td colspan="3">Management Priorities:</td></tr><tr><td colspan="3" style="text-align:justify;"><ul><li>Relief of pain</li><li>Address the reason for attendance/presenting complaint (Form 21)</li><li>Life threatening problems (e.g. OM, OP, OS, infections)</li><li>Inflammatory conditions (e.g. Endo, Perio, OS, infections.)</li><li>Caries management (includes prevention and restorations)</li><li>Assessment and replacement of restorations for non-carious reasons (e.g. fracture, aesthetics)</li><li>Reassessment</li><li>Repositioning (orthodontics if required)</li><li>Prosthodontics (indirect restorations, dentures, implants, splints)</li><li>Review, reassessment and ongoing care (includes regular debridement, follow-up of endodontic and prosthodontic treatment)</li><li>Review, reassessment and ongoing care (includes regular debridement, follow-up of endodontic and prosthodontic treatment)</li></ul></td></tr><tr><td colspan="3" style="text-align:justify;">PMP to include:</td></tr><tr><td colspan="3" style="text-align:justify;"><ul><li>Order of procedures (tooth by tooth) according to priority</li><li>Appointment outline – time, procedure, proposed date</li><li>Further investigations/referrals required</li></ul></td></tr><tr><td colspan="3" style="text-align:justify;">Relief of Pain _________________________________________________________ _________________________________________________________ _________________________________________________________ <div style="text-align:right;">Supervisor’s signature for palliative treatment by student: ______________________ ------------------------- Clinician Code: ______________________</div></td></tr><tr><td colspan="3" style="text-align:center; vertical-align:middle;">Address the reason for attendance/presenting complaint (Form 21) _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ 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_________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ ![](Form 23 - Patient Management Plan_figures/img_b80a568d14a6eacd.webp) Use Patient Barcode Label Given Name: ______________________ Surname: ______________________ DOB: ______________________ TEMP: ______________________ Clinician: ______________________ Clinician ID: ______________________ Date: ______________________ #### Management Priorities - Relief of pain - Address the reason for attendance/presenting complaint (Form 21) - Life threatening problems (e.g. OM, OP, OS, infections) - Inflammatory conditions (e.g. Endo, Perio, OS, infections) - Caries management (includes prevention and restorations) - Assessment and replacement of restorations for non-carious reasons (e.g. fracture, aesthetics) - Reassessment - Repositioning (orthodontics if required) - Prosthodontics (indirect restorations, dentures, implants, splints) - Review, reassessment and ongoing care (includes regular debridement, follow-up of endodontic and prosthodontic treatment) #### PMP to Include - Order of procedures (tooth by tooth) according to priority - Appointment outline – time, procedure, proposed date - Further investigations/referrals required #### Relief of Pain _________________________________________________________ _________________________________________________________ _________________________________________________________ Supervisor’s signature for palliative treatment by student: ______________________ Clinician Code: ______________________ #### Address the Reason for Attendance / Presenting Complaint (Form 21) _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Table-like structure containing fields for patient barcode label information including Given Name, Surname, DOB, and TEMP. Form 23 Patient Management Plan continuation Form 23 Caries management (includes prevention and restorations) Assessment and replacement of restorations for non-carious reasons (e.g. fracture, aesthetics) Reassessment Repositioning (orthodontics if required) Prosthodontics (indirect restorations, dentures, implants, splints) Review, reassessment and ongoing care (includes regular debridement, follow-up of endodontic and prosthodontic treatment) Patient Management Plan Authorised by: (for student clinicians) Clinician ID: Date: I understand and agree to the suggested treatment plan Parent/Guardian Signature: Parent/Guardian Name: Date: Form 23_Version 1/2012_page 2 of 2 ![](Form 23 - Patient Management Plan_figures/img_ca980a49f985a559.webp) ![](Form 23 - Patient Management Plan_figures/img_8d91981acc075610.webp) ![](Form 23 - Patient Management Plan_figures/img_60d26f441e67cb1e.webp) ![](Form 23 - Patient Management Plan_figures/img_7792b46ec8131ecc.webp) ![](Form 23 - Patient Management Plan_figures/img_24f68ffab470e80c.webp) - Caries management (includes prevention and restorations) - Assessment and replacement of restorations for non-carious reasons (e.g. fracture, aesthetics) - Reassessment - Repositioning (orthodontics if required) - Prosthodontics (indirect restorations, dentures, implants, splints) - Review, reassessment and ongoing care (includes regular debridement, follow-up of endodontic and prosthodontic treatment) Patient Management Plan Authorised by: (for student clinicians) Clinician ID: Date: I understand and agree to the suggested treatment plan Parent/Guardian Signature: Parent/Guardian Name: Date: Table cell labeled 'Caries management (includes prevention and restorations)' containing empty space for input. Table cell labeled 'Assessment and replacement of restorations for non-carious reasons (e.g. fracture, aesthetics)' containing empty space for input. Table cell labeled 'Reassessment' containing empty space for input. Table cell labeled 'Repositioning (orthodontics if required)' containing empty space for input. Table cell labeled 'Prosthodontics (indirect restorations, dentures, implants, splints)' containing empty space for input. [^1]: Original PDF page 1: [[Form 23 - Patient Management Plan.pdf#page=1|Form 23 - Patient Management Plan, p.1]] [^2]: Original PDF page 2: [[Form 23 - Patient Management Plan.pdf#page=2|Form 23 - Patient Management Plan, p.2]]