Chapter 10: Documentation for Dental Hygiene Care

Patient Record

basis for evaluating patient quality of care

considered legal evidence

must be authentic, accurate, comprehensive, legible, and objective

recorded promptly, legibly, accurately, dated and signed by clinician

required components → med hx/vitals, dental hx, assessment and diagnosis, tx plan, progress notes, and hipaa acknowledgment

Handwritten Dental Records

• must in legible and in ink

• when correcting a mistake, one line should strike through the old material and correction should directly follow

• must use strict infection control

• need a filing system

Electronic Dental Records

authorized personnel can access

infection control for keyboard and mouse

enhances communication with the patient and specialists

faster, more convenient, and more organized than paper documentation

Health Insurance Portability and Accountability Act (HIPAA)

took effect in 2003

protects pt records and other health-related information

patients have the right to:

• receive copy of their records

• change any information

• decide what the share and who to share with

• how they wish to be contacted regarding their information

Healthcare Facilities and HIPAA

develop required privacy and confidentiality forms

educate the staff on guidelines

implement security protocols to further protect patients

Healthcare Providers and HIPAA

comply with protocols and practices that protect patient information

Universal Tooth Numbering System

Permanent Teeth: 1-32 starting in upper right

Primary (baby) Teeth: A-T

ADA System and most commonly used

Federation Dentaire Internationale Two Digit System

hardly used in dental practice

1- UR

2- UL

3- LL

4- LR

starts at midline and goes lateral (ex: UR central incisor is 11 and UR 3rd molar is 18)

Palmer Notation System

Uses L-Brackets

maxillary R → backwards L

maxillary L → L

Mandibular R → upside down, backwards L

Mandibular L → upside down L

Primary Teeth go from A to E, and permanent teeth go from 1-8

Items that Must be Charted

• missing teeth

• existing restorations

• fixed/removable prostheses

• sealants

• abrasion and erosion

• overhangs, open contacts, and proximal roughness

• pulp vitality

• tooth sensitivity

Purpose of Documenting for Patient Care

chronological history of tx received by pt during appointment

document all aspects of process of care and record interactions between patient and DH

Essentials of Good Documentation

must be professional

no speculation or derogatory statements in charts

• bad encounters must be documented in a professional manner

Charting Periodontal Records (gingiva around the teeth)

1. Examine Gingiva and record findings before applying disclosing agent for biofilms core

2. describe gingiva color, shape, consistency, surface texture, and extent of bleeding

3. describe distribution and gingival changes- localized or generalized, mild moderate or severe