Ontario Society of Oral and Maxillofacial Surgeons
Surgical Complications Data Collection

Note: This survey is an anonymized data collection tool for the use of OSOMS. Its purpose is to enable the Society to provide suggestions of evidence-based improvements to patient care. Patient-specific information will never be requested of its members.

Question Title

* 1. Date of Patient Presentation

Date

Question Title

* 2. Classify Complication

Non-Preventable

Potentially Preventable

Preventable

Question Title

* 3. Classify Complication Severity

Very Serious

Serious

Not Serious

Question Title

* 4. Brief Summary of incident/complication

Question Title

* 5. Surgical Management required?

Yes

Question Title

* 6. If consultation and/or treatment was done in office, what dental billing codes were used?

Question Title

* 7. Location Treatment Performed

Office

Hospital Clinic

Emergency Department

Hospital Operating Room

Other (please specify)

Question Title

* 8. OHIP billed services by OMFS required?

Yes

Question Title

* 9. Did the complication result in the use of hospital resources?

Yes

Question Title

* 10. How was patient referred to OMFS

Referred by treating DDS

Referral from Emergency Department

Other (please specify)