DEH 1005 Week 7 Flashcards

Dental Software & Documentation

Which dental software system does PPSC use?

Dentrix Ascend (AKA Academic Ascend or just Ascend)

What is Academic Ascend used for?

• Scheduling appointments

• Clinical charting

• Patient records

• Dental imaging

• Treatment planning

• Clinical notes

• Patient communication

• Billing

What are the components of a comprehensive patient record?

• HIPPA acknowledgment

• Patient Bill of Rights and Responsibilities

• Medical and dental history

• Clinical assessments

• Head and neck exam

• Intraoral/extraoral exam

• Hard tissue exam

• Periodontal examination and assessment

• Radiographs

• Clinical photographs

• Diagnostic tests

• Study models/digital scans

• Risk assessments

• Dental hygiene diagnosis

• Treatment plan

• Informed consent

• Informed refusal

• Treatment rendered

• Prescriptions

• Referrals

• Communications with providers

• Patient communications

• Missed appointments

• Cancellations

• Patient education

• Patient noncompliance

What should be documented if a patient refuses treatment?

Document the recommended treatment, that the patient refused, the discussion of risks/benefits/alternatives, the patient’s understanding, and obtain an informed refusal signature if applicable

Why is documenting treatment refusal important?

It provides legal protection by showing the patient made an informed decision

Can a dental hygienist diagnose cavities?

No. Cavities are diagnosed by the dentist

What can a dental hygienist diagnose?

Dental hygiene diagnoses related to oral health conditions within the hygiene scope of practice

What are some examples of things dental hygienists can diagnose?

• Gingivitis

• Periodontitis (periodontal disease)

• Heavy plaque accumulation

• Moderate to heavy calculus deposits

• Generalized bleeding on probing

• Poor oral hygiene/self-care

• High caries risk (only risk assessment, not diagnosing the cavity)

• Xerostomia (dry mouth) affecting oral health

• Localized gingival recession

• Areas requiring periodontal maintenance

What are examples of things dental hygienists cannot diagnose?

• Dental caries (cavities)

• A tooth requiring a root canal

• A cracked tooth

• An abscess

• Oral cancer (may identify suspicious lesion and refer but cannot diagnose)

What is an easy trick for remembering what dental hygienists can or cannot diagnose?

Hygienists diagnose periodontal and preventive care needs. Dentists diagnose diseases requiring restorative or surgical treatment.

What is the dental hygienist’s primary clinical examination?

The periodontal examination and assessment

What is included in a comprehensive periodontal examination?

• Probing depths

• Bleeding on probing

• Gingival recession

• Clinical attachment level/attachment loss

• Plaque

• Calculus

• Gingival health/disease

• Bone height/bone loss (periodontal disease)

• Mobility

• Fremitus

• Furcation involvement

• Suppuration (puss)

What is not included in the periodontal examination?

Diagnosing cavities and evaluating root canal therapy

How should periodontal probing be performed?

Hit all 6 spots

1. Mesiobuccal

2. Mid-buccal

3. Distobuccal

4. Mesiolingual

5. Mid-lingual

6. Distolingual

Bone loss is an indication of what disease?

Periodontal disease

How often should a comprehensive periodontal examination be documented?

At every patient visit and documented at least once yearly

Why is documentation one of the most important responsibilities of a dental hygienist?

• Maintains continuity of care

• Communicates with providers

• Protects the clinician legally

• Demonstrates quality of care

• Serves as a legal document

What is the most important documentation rule?

If it isn’t documented, it didn’t happen

Good documentation should be:

• Accurate

• Objective

• Complete

• Chronological

• Legible

• Clear

• Concise

• Promptly recorded

• Dated

• Signed

Why must documentation be objective?

Patient records are legal documents and should contain factual observations rather than opinions or assumptions

Can dental hygienists use abbreviations in chart notes?

Only medically accepted or practice-approved abbreviations should be used

Why should documentation be completed immediately after treatment?

To reduce errors, preserve accuracy, and strengthen legal credibility

Why are patient records considered legal documents?

They may be used as evidence in malpractice cases, board investigations, insurance audits, and other legal proceedings

What patient communications should always be documented?

• Phone calls

• Emails

• Text messages

• Referrals

• Prescriptions

• Missed appointments

• Cancellations

• Treatment refusal

• Patient noncompliance

What documentation format is commonly used in dental hygiene?

Premade documentation templates organized in the chronological order of the dental hygiene examination and appointment

Why are documentation templates used?

• Promote consistency

• Improve efficiency

• Ensure complete documentation

• Create a chronological record of care

• Reduce omissions