Dental Hygiene Documentation: Records, Privacy, and Charting

Why is complete and accurate documentation important in dental care?

It facilitates communication, coordinated planning, and enhances continuity of care.

What actions are essential for accurate documentation of patient care?

Documentation must be recorded promptly after treatment, using clear, concise statements that are accurate, legible, objective, and signed by the clinician.

What are five types of documentation in a comprehensive patient dental record?

Informed Consent, Periodontal records, Dental History records, Care plan records, Treatment records.

What types of information should not be included in a patient's dental record?

Personal opinion, speculation, derogatory statements, financial disputes, and legal or risk management information.

What are the important components of a patient's dental record?

Medical history/vital signs, Clinical assessment (charting, periodontal exam, intraoral photos, x-rays), Diagnosis/prognosis, treatment recommendations, informed consent/refusal for treatment.

What must handwritten records be recorded in?

Ink.

What does HIPAA stand for in the United States?

Health Insurance Portability and Accountability Act.

What does PIPEDA stand for in Canada?

Personal Information Protection and Electronic Documents Act.

What rights are protected by HIPAA?

The privacy of the patient and the patient's ability to access their information.

What are the responsibilities of healthcare providers under HIPAA?

Complying with protocols that protect patient information and avoiding inappropriate disclosure.

What is the purpose of maintaining complete and accurate periodontal and dental records?

To aid in care planning, treatment, evaluation, protection, and identification.

What types of chart forms can be used for dental charting?

Anatomic drawings of teeth and geometric forms.

What is a systematic procedure in dental charting?

Using a set routine to complete accurate charting, such as charting all restorations first before detailing deviations.

What should be described when observing gingival changes?

Color, size, position, shape, consistency, surface texture, bleeding, and any changes in gingiva.

What items are documented in a dental charting record?

Missing teeth, unerupted or supernumerary teeth, existing restorations, fixed/removable prosthesis, dental sealants, abrasion, erosion, carious lesions, and pulp vitality.

What factors are included in a patient progress note?

Purpose of the visit, history review, assessment findings, treatment description, drugs administered, oral self-care instructions, referrals, lab test results, and clinician signature.

What does the 'S' in the SOAP note method stand for?

Subjective - includes patient report, age, gender, treatment plan, medical history, medications, allergies, chief complaint, and social history.

What does the 'O' in the SOAP note method represent?

Objective - clinician observations and results from clinical examinations.

What is assessed in the 'Assessment' section of the SOAP note?

Diagnosis, risk factors for oral disease, and current periodontal diagnosis.

What does the 'P' in the SOAP note method stand for?

Plans - detailing dental hygiene treatment provided, medications, consultations, and oral self-care instructions.