CH10: Documentation for dental hygiene care

The patient record

Accurate record keeping is essential to a safe, thorough, and caring dental hygiene practice as well as clinical and ethical risk management.

Purpose and characteristics

• Complete & Accurate documentation of patient information and treatment provided

• Serves as a basis for the evaluation of the quality of care

• Data from health records are utilized in research and education

• Documentation in the patient’s record is considered legal evidence in any legal or forensic situation

Documentation is

Authentic, genuine and undisputed reality

Accurate and comprehensive

Legible

Objective

Patient record entries are

Recorded promptly during or following treatment

Recorded using clear, concise, objective statements

Dated

Signed by the clinician

Components of a patient record

• Medical history

• Vitals

• Dental history

• Clinical assessment

• Clinical diagnosis

• Treatment recommendations

• Written treatment plan

• Progress notes for each visit

• Signed acknowledgement of confidentiality measures

• Informed consent forms

• Radiographs

• Periodontal risk assessment

• Caries risk assessment

• Trauma and/or surgery

• Anesthesia records

• Study Models

• Oral photographs

• Orthodontic records

• Laboratory orders and test results

• Referral records

The health insurance portability and accountability act (HIPPA)

Provides federal privacy standards that protect patient records and other health-related information

Law applies to:

• Healthcare facilities

• Healthcare insurance companies

• Healthcare providers

Universal tooth numbering system

Federation dental international two digit system

Palmer notation system

Which tooth numbering system is used for orthodontics?

palmer notation system

Patient profile

brief description

not subjective

objective information

Chief concern

why is the patient here?

what is THEIR BIGGEST concern

Health history

Thorough Review of Medical/Dental history

Significant medical conditions

Vitals

Medications and supplements

Allergies

ASA Classification (evidenced by)

Recommended radiographs

• What did you take?

• Why?

• PA #3 due to radiolucent finding on panoramic film

• Any retakes?

type what you recommend, since we don't prescribe. Explain why. Stuff from radiograph is put in treatment rendered (TX R)

bases on individual needs (ALARA, ADA, dentist)

Dental hygiene diagnosis

• Periodontal Classification

(description of evidence)

• Calculus Classification (location, deposit type)

• Caries risk

• Plaque score/Biofilm Index

Treatment rendered

• What did you do today?

• In what order?

-what radiographs did you end of taking? Ex) PA #3 due to radiolucent finding on panoramic film; Any retakes?

• Patient education/goals

• Products recommended

• Was recommended treatment declined by patient? DOCUMENT

here!

• How did the patient respond to treatment

Recommended referrals

DOES THE PATIENT NEED TO BE REFERRED TO A SPECIALIST?

DOES THE PATIENT NEED TO BE REFERRED TO A DIFFERENT FACILITY?

We aren't anyone's dental home.

Always refer to their dental home or find one

We only do preventative not restorative stuff in the IUSB clinic

OK

Next visit

What are you going to accomplish at the patient’s next visit?

Follow up procedure

Recall recommendations