Chapter 22:Dental hygiene care plan, evalution, and documentation

planning phase

diagnosed client needs are prioritized, client goals and evaluative measures are established, and intervention strategies are determined

purpose of planning phase

develop a plan of care that results in the resolution of an oral health problem amenable to dental hygiene care, the prevention of a problem, or the promotion of oral and general health

electronic health record (EHR)

multi-purpose health information technology system that compiles comprehensive client information and makes it readily available to the healthcare team

phases of dental hygiene process of care

assessing, diagnosing, planning, implementing, evaluating, documenting

client centered goal

is the client's desired outcome achieve through specific dental hygiene intervention strategies to satisfy an unmet human need related to dental hygiene care

cognitive goals

Target increases and the clients knowledge and understanding

psychomotor goals

focus on the client's skill development and skill Mastery

affective goals

pinpoint desired changes in client values, beliefs, and attitudes

oral health status goals

address the signs and symptoms of oral disease and reflect a desired Health outcome achievable through dental hygiene interventions

what should each client-centered goal have?

a subject, a verb, a Criterion for measurement, and a Time dimension for evaluation

subject in client centered goal

the client or clients caregiver

verb in client-centered goal

the client action desired to achieve the desired outcome

not the action of the dental hygienist

Criterion

the observable Behavior or desired tangible outcome

time dimension

denotes when the client is to have achieved a goal

Target time maybe a specific date or a statement

how does collaboration improve client goals?

individuals are more likely to express commitment to a care plan and their willingness to change if they share in the development of goals, priorities, interventions, and appointment planning

dental hygiene interventions

the evidence-based strategies, products, and procedures that, if applied, reduce, eliminate, or prevent the oral health problems

what do interventions address?

the factors contributing to the clients human need deficit

appointment schedule

becomes a guide for implementing the proposed interventions

appointment schedule specifies the following:

•number of visits

•time needed for each visit

•interventions to be implemented at each visit

presentation and discussion of dental hygiene care plan include the following

•nature of the condition

•proposed care plan

•risks involved (if any)

•potential for failure

•expected outcomes if the problem goes untreated •alternative procedures

informed consent

client's acceptance of care after a discussion with health care provider regarding the proposed care plan and risk of not receiving care

client must give consent for

•a specific treatment

•a procedure that is legal

•under truthful conditions

T/F: informed consent should be viewed as a one time activity.

False; it is viewed as ongoing process in which the client is informed continuously and reminded of the terms of care

for informed consent to be achieved:

•client must be knowledgeable on tx planned

•client needs enough info to make rational choice

•give permission for plan to be carried out

when is implied consent given?

when a client voluntarily comes to the oral setting and sits in the dental chair

What did implied consent apply to?

only the assessment, diagnosis, and planning components DHPC

what if a client request care, that in the opinion of the hygienist or dentist, is unwarranted, inappropriate or dangerous?

he or she should refuse to provide care and should encourage the client to seek a second professional opinion

T/F: as a rule, the client never should be allowed to dictate treatment.

True

evaluation goal in process of care

document success of the care plan interventions strategies at achieving the proposed care plan goals

evaluation

critical component to successful outcome of dental hygiene care

Why is evalution a critical component to process of care?

allows clinician to measure short-term achievement of client centered goals and anticipate clients long term prognosis in maintaining the goals achieved

how are evaluation strategies defined?

by client centered goals during the planning phase and applied during implementation phase, at completion of the dental hygiene care planned, and at the subsequent Continued Care visit to measure the clients continued success at maintaining the previously achieved outcome

ongoing monitoring

the clinician continually measures client progress toward achieving the goals, or the desired outcomes

what does evaluation of client centered goals determine?

whether dental hygiene care has achieved the client's unmet human need

how does evaluation help clinician when intervention or therapy was unsuccessful?

•modify care plan because client is having difficulty in achieving goal

• modify care plan because client is not ready to achieve goal

•continue the care plan because client needs more trying to achieve goal

•terminate the care plan because the client has achieved the goal

evaluation of client centered goals strategy

•ask client open ended questions to meet to measure acquisition of new knowledge (cognitive)

• have client demonstrate a newly learned interdental cleaning technique (psychomotor)

• having client report increased motivation to stop smoking by attempting to smoke fewer cigarettes per day (affective)

• showing client clinical improvements in oral health (oral health status)

what does a written evaluative statement include?

dental hygienist's decision on the degree to which the goal was achieved and concrete evidence that supports that decision

T/F: from a legal perspective, failure to evaluate the outcome of care may be grounds for negligence (malpractice)

True

dental hygiene prognosis is contingent on the following

overall appraisal of the evaluative statements

clients continued adherence to recommended self-care

level of optimum oral health achieved

favorable prognosis

when risk for a new disease or occurrence of the previous conditions is low

guarded prognosis

risk for a new disease or recurrence of the previous condition is moderate to high

example risk factors such as smoking or uncontrolled systemic disease

Continued Care visit begins with

reassessment of the clients human needs related to oral health to provide evidence of the long-term outcome of the previous care plan and need for supportive care

goals of evaluation at Continued Care visit

document client evidence of continued oral health from previous cycle of care

identify a reoccurrence of an unmet need

identify a new condition that may be present

formulate a care plan that supports the clients continued needs

supervised neglect

occurs when the client continues to require for their dental hygiene care to achieve higher levels of oral Wellness or to prevent or control oral disease progression, yet the client has been discharged erroneously from care, thinking that a healthy state was achieved

where can supervised neglect occur?

in practices that have a service oriented approach to client care rather than a client-centered approach

service-oriented practice

applies the same series of services, appointment time, and Continued Care recommendations to all clients

documentation

complete and accurate recording of all collected data, care plan and provided, recommendations, and other information relevant to client care

Assessment documenting guideline

include demographic client data; personal, medical, dental, pharmacological health history; Vital Signs; head and neck examination ;findings dental and periodontal examination; findings caries risk assessment; oral self care practices ;client Chief concern ;client Readiness to change ;oral habits

dental hygiene diagnosis documenting guideline

document a statement of client needs supported by related clinical evidence and contributing factors

care plan documenting guideline

document the proposed care plan and a statement of client-centered goals, evidence-based interventions, and supportive appointment schedule

summarize client involvement and development of care plan

presentation of care plan to client documenting guideline

document client-clinician discussion of proposed care plan, valid informed consent and or informed refusal

implementation of care plan documenting guideline

document, in detail, implementation of all care provided in chronological order of appointments

include the clients adherence to the appointment scheduled (e.g., late arrival,cancelled, rescheduled, failed appointment)

evaluative statement of outcome

document complete evaluated statement of outcome and summary of evaluation methodology

describe clinician action based on outcome of care

indicate that outcome and prognosis were discussed with client

what should conclude a documentation entry?

date and signature of clinician

what can ensure a client-centered approach to care

integrating care planning, evaluation, and documentation into dental hygiene care

preliminary phase:emergency care

relief of pain

lab test for suspected pathology

emergency needs

Ext's of hopeless teeth

provisional replacement to restore function

NOT INCLUDED IN DHCP

factors influencing how priorities are established

client values, beliefs, and attitudes

healthcare provider philosophy

collaborating dentist's goals

client health status

whether the client is experiencing infection, discomfort, anxiety, or pain

T/F: goals evaluated too early restrict the clinician's and the client's ability to determine the impact of care provided

True

clients need time to

internalize information

practice new skills

experience physical and attitudinal changes related to oral health and wellness

assess the importance of these changes to their lifestyle

adopt the new Behavior

what should be done to achieve the desired outcomes?

evidence-based interventions must address specifically the factors contributing to the clients unmet human need

what should be considered when appointment schedule is planned?

time needed for each intervention

logic of grouping interrelated procedures

status and severity of unmet human needs

clients tolerance for long sessions

client scheduling requirements

implementation in one visit

when unmet client needs and proposed care plan goals are easily attainable

multiple appointments

when diagnosis, client goals, and interventions are complex

T/F: once agreed on in writing by the client, the care plan becomes a legal contract between the dental hygienist and the client

true

informed refusal

client May decline all or part of proposed care plan

the clinician should have the client sign an electronic was Declaration of informed refusal that remains part of the clients EHR

what should clinician do if client refuses treatment?

client refusal must be analyzed to determine how or why the client arrived at that decision

client reasons for refusal of care

cost of service, fear of pain, lack of understanding, low value placed on Dental Care, lack of dental insurance coverage

clinician actions when client refuses care

acknowledged clients concerns, clarify proposed plan of care, discuss consequences of not receiving recommended care, recommend alternative treatment options when appropriate

factors influencing client goal attainment

client who values oral health, is motivated, and has a sense of inquiry

dental hygienists who maintains and evidence based practice

work environment that values high quality Healthcare and offers incentives for care that meet or exceed recognized standards of practice

what should be done at termination of dental hygiene care plan, once the goal has been met?

a new process of care cycle is recommended to the client for Continued Care

what is critical to attaining a successful outcome for the client?

ongoing collaboration between the dental hygienist, dentist, and physician (when warranted)

when is the dental hygiene care plan written?

immediately after the assessment and diagnosis phases of the process of care and in conjunction with the overall dental treatment plan prepared by the dentist

characteristics of a well-written dental hygiene care plan

reflects goals of care to 1 develop and maintain the individuals behaviors essential to oral health and the Mastery of self care and the environment 2 prevent oral disease using primary, secondary and tertiary preventive interventions and 3 promote Wellness

establishing priorities or based on:

threatens the client's well-being; it is important to distinguish unmet needs that pose the greatest threat to the client safety, health, and comfort from those that are not life-threatening and or related to a current oral disease

can be address simultaneously with other diagnosis

is a client priority

factors influencing her priorities are established:

client values, beliefs, and attitudes

healthcare provider philosophy

collaborating dentist goals

client health status

whether the client is experiencing infection, discomfort, anxiety, or pain

In which phase of the dental hygiene process of care are diagnosed client needs prioritized, client goals and evaluative measures established, and intervention strategies determined?

A. Assessment

B. Diagnosis

C. Planning

D. Implementation

E. Evaluation

c

The planning phase of the dental hygiene process of care is undertaken after the assessing and diagnosing phases and facilitates the development of the dental hygiene care plan. The planning phase involves prioritization of client needs, establishment of client-centered goals, and selection of intervention strategies to address a client's unmet human needs.

The purpose of the planning phase is to develop a care plan that will result in the resolution of an oral health problem amenable to dental hygiene care, the prevention of a problem, or the promotion of oral health. Therefore the dental hygiene care plan is independent of the dental treatment plan.

A. Both statements are true.

B. Both statements are false.

C. The first statement is true, and the second statement is false.

D. The first statement is false, and the second statement is true.

C

The purpose of the planning phase of the dental hygiene process of care is to develop a plan of care that will result in the resolution of an oral health problem amenable to dental hygiene care, the prevention of the problem, or the promotion of oral health. The second statement is false. The dental hygiene care plan is developed in collaboration with the comprehensive dental plan and supports the dental plan.

The foundation for development of a client-centered dental hygiene care plan is the:

A. Dental hygiene diagnosis

B. Client-centered goal

C. Dental hygiene intervention

D. Client's desired outcome

A

Development of a dental hygiene care plan occurs as a collaboration or partnership between which of the following?

A. Dental hygienist and dentist

B. Dental hygienist and client

C. Dentist and client

D. Dental hygienist develops care plan independently.

B

When is the dental hygiene care plan written?

A. Immediately after the assessment and diagnosis phases of the process of care

B. During the implementation of phase I therapy

C. After phase I therapy

D. At the 6-month continued-care appointment

A

The dental hygiene care plan is written immediately after the assessing and diagnosing phases of the process of care to establish a plan that will address a client's unmet need.

In dental hygiene care planning, a client-centered goal defines the clinician's desired outcome of care. Therefore client-centered goals must reflect the contributing factors of the dental hygiene diagnosis for unmet human needs.

A. Both statements are true.

B. Both statements are false.

C. The first statement is true, and the second statement is false.

D. The first statement is false, and the second statement is true.

B

Both statements are false. A client-centered goal defines the client's outcome of care that is supported by the clinician. Client-centered goals address the signs and symptoms of the dental hygiene diagnosis for an unmet human need.

Which one of the following represents a client-centered goal written in the affective domain?

A. The client will understand the composition of oral biofilm and its role in the progression of periodontal disease by 7/12.

B. The client will report including a power toothbrush in daily oral self-care by 11/3.

C. The client will successfully demonstrate flossing technique by 9/10.

D. The client will decrease bleeding on probing by 80% by 9/21.

B

A client-centered goal written in the affective domain targets changes in behaviors based on client values, beliefs, and attitudes. "The client will report including a power toothbrush in daily oral self-care by 11/3" is written in the affective domain.

"Client was diagnosed with an unmet human need for a biologically sound dentition due to exposed cemented in mandibular premolar and molar areas as evidenced by client complaining of sensitivity to cold foods and drinks." Which of the following best represents an oral health status goal for this diagnostic statement?

A. Client will eliminate dental hypersensitivity by 1/22.

B. Client will report daily use of self-applied topical fluoride gel.

C. Client will purchase a soft-bristle toothbrush and desensitizing toothpaste by 4/21.

D. Client will demonstrate modified basic toothbrushing technique in molar and premolar areas by 6/6.

A

"Client will eliminate dental hypersensitivity by 1/22" best represents an oral health status goal for a dental hygiene diagnosis of an "unmet human need for biologically sound dentition due to exposed cemented in mandibular premolar and molar areas as evidenced by the client complaining of sensitivity to cold foods and drinks." Oral health status goals target changes in the signs and symptoms of an oral disease and reflect a desired health outcome.

A well-written client-centered goal will have a subject, a verb, criteria for measurement, and a specified time dimension. The criteria describe the expected outcome.

A. Both statements are true.

B. Both statements are false.

C. The first statement is true, and the second statement is false.

D. The first statement is false, and the second statement is true.

A

In the development of a dental hygiene care plan, strategies selected to reduce, eliminate, or prevent an oral health problem are:

A. Expected outcomes

B. Oral health goals

C. Dental interventions

D. Dental hygiene interventions

D

In the development of a dental hygiene care plan, evidence-based interventions are the strategies selected from the dental hygiene scope of practice to reduce, eliminate, or prevent an oral health problem (e.g., oral self-care instructions, periodontal debridement, selective coronal polishing).

Q. At which stage of care plan development are oral self-care strategies sequenced into planned appointments?

A. Prioritizing dental hygiene diagnoses

B. Setting client-centered goals

C. Selecting dental hygiene interventions

D. Establishing the appointment schedule

D

Oral self-care strategies are sequenced into planned appointments during the establishment of the appointment schedule. The appointment schedule is a guide for implementing all proposed dental hygiene interventions. Interventions are prioritized then integrated into planned appointments that will best meet the client's desired outcome of care.

Q. Intervention strategies in a dental hygiene care plan specifically address which of the following?

A. Signs and symptoms of the problem

B. Cause of the problem

C. The goal of the dental hygienist and dentist

D. The appointment time available

B

Intervention strategies in the dental hygiene care plan specifically address the cause of the problem. Intervention strategies are linked to the dental hygiene diagnosis by addressing the factors determined to be contributing to the problem.

Q. The best intervention strategy to ensure that a client is skilled to perform a recommended oral self-care technique is to:

A. Have the clinician demonstrate the technique on a model

B. Ask the client to describe the technique

C. Have the client demonstrate the technique intraorally

D. Wait until the next continued-care appointment and reevaluate the client's oral health status

C

The dental hygienist formulates a client-centered care plan that supports the dental treatment plan; the dental hygienist has the ethical and legal responsibility to communicate the plan to the client and obtain informed consent.

A. Both statements are true.

B. Both statements are false.

C. The first statement is true, and the second statement false.

D. The first statement is false, and the second statement is true.

A

The dental hygienist must formulate a comprehensive, client-centered care plan that supports the dental treatment plan. Before implementing the care plan, the dental hygienist has the ethical and legal responsibility to communicate the plan to the client and obtain informed consent.

What is the legal term that indicates that the client is knowledgeable about the services the healthcare provider proposes to render but that the client declines the care?

A. Implied consent

B. Informed refusal

C. Informed consent

D. Expressed consent

B

Which phase of the process of care is critical to determining the quality of the dental hygiene care plan in achieving the client's desired outcome?

A. Assessment

B. Diagnosis

C. Planning

D. Implementation

E. Evaluation

E

Evaluating, the fifth phase of the process of care, is critical to determining the quality of the dental hygiene care plan in achieving the client's desired outcome.

Which one of the following is the proper sequence for developing a dental hygiene care plan?

A. Prioritize client's unmet needs, set goals, select interventions, establish appointment schedule.

B. Set goals, select interventions, prioritize client's unmet needs, establish appointment schedule.

C. Prioritize interventions, define need, set goals, establish an appointment schedule.

D. Establish length of appointment, set goals, select interventions, establish informed consent.

A

During development of a multiappointment dental hygiene care plan, a successful self-care management strategy is to sequence small increments of client education into each visit. This strategy is recommended to shape the client's self-care responsibilities.

A. Both the statement and the reason are correct, and they are related.

B. Both the statement and the reason are correct, but they are not related.

C. The statement is correct, but the reason is not.

D. The statement is not correct, but the reason is correct.

E. Neither the statement nor the reason is correct.

A

Both the statement and the reason are correct, and they are related.

Strategies for evaluating the outcome of dental hygiene care are guided by which of the following?

A. Dental hygiene diagnosis

B. Client-centered goals

C. Dental hygiene intervention strategies

D. Appointment schedule

B

Client-centered goals define the strategies for evaluating the outcome of dental hygiene care. Methods of evaluating the outcome of dental hygiene care reflect the action and observable behavior defined by the goal.

Failure to evaluate a client's progress at each subsequent continued care visit can lead to:

A. supervised neglect

B. informed consent

C. client centered evaluation

D. collaboration interventions

A

How does the utilization of electronic health records (EHR) and digital images during the care plan presentation, strengthen a client's understanding and acceptance of the diagnosed condition and proposed care plan?

A. interactive educational software that is linked to the EHR can be used to familiarize the client with proposed treatment strategies or expected treatment outcomes

B. it allows the care plan to be presented to the client after preventive and therapeutic services have been initiated.

C. It prevents the dental hygienist from having to obtain the client's informed consent in a timely manner

D. digital images of the client's oral assessment findings can be displayed on a screen and used to provide a visual evidence of the client's condition

D

After a discussion with the healthcare provider regarding the proposed care plan and risks of not receiving care, the client will be asked to do which of the following?

A. inform consent

B. approve provider

C. inform refusal

D. disapprove provider

A

A client was diagnosed with a human need for wholesome facial image due to the client's dissatisfaction with her malaligned maxillary anterior teeth as evidenced by the client verbalizing, "I try not to show my teeth when smiling." The dental hygienist, in collaboration with the client, set the following goal: The client will seek an orthodontic consultation by 7/12.

Which of the following intervention strategies will best address this proposed goal?

A. Educate client on benefits of orthodontic therapy.

B. Review client's oral self-care techniques in sextant 2.

C. Debride teeth of soft deposits in sextant 2.

D. Refer client to orthodontic specialist for consultation.

D

The intervention strategy "Refer client to orthodontic specialist for consultation" will best address the stated goal. A referral by the clinician directly addresses the action of the client-centered goal "will seek."

A client was diagnosed with a human need for wholesome facial image due to the client's dissatisfaction with her malaligned maxillary anterior teeth as evidenced by the client verbalizing, "I try not to show my teeth when smiling." The dental hygienist, in collaboration with the client, set the following goal: The client will seek an orthodontic consultation by 7/12.

Which of the following evaluative statements best measures the outcome of this goal?

A. Goal met, client recognizes the benefits of orthodontic therapy.

B. Goal partially met, client is brushing 1 × day.

C. Goal met, client attended orthodontic consultation on 7/2.

D. Goal met, client researched the risks and benefits of orthodontic therapy.

C

According to the dental hygiene process of care, when evaluation reveals that the client has made little progress toward goal attainment, the dental hygienist does all of the following except which one?

A. Terminate care.

B. Reassess the client.

C. Modify dental hygiene diagnoses.

D. Modify the care plan.

A