Dental Hygiene Care Plan, Evaluation, and Documentation Notes

Dental Hygiene Care Plan, Evaluation, and Documentation Chapter 23

Learning Objectives

  • Purpose of Electronic Record Keeping for Patient Care: Understanding the importance and role of electronic records in ensuring comprehensive patient care.

  • Criteria/Components of SOAPS Clinical Notes: Identify and explain the components associated with each section of SOAPS clinical notes, which stands for Subjective, Objective, Assessment, Plan, Services, and Next Visit.

  • Demonstrating SOAPS Clinical Notes: Showcase accuracy and thoroughness in compiling SOAPS clinical notes.

  • Documentation Importance: Understand the phrase "if it isn’t documented, it didn’t happen" emphasizing the necessity of comprehensive documentation in patient care.

  • Significance of Periodontal Assessment: Relate the periodontal assessment to the dental hygiene process of care, recognizing its implications on the overall treatment plan.

Dental Hygiene Diagnosis

  • Cognitive Modifications: Dental hygiene diagnosis considers the need for modifications to oral hygiene instructions based on the patient’s cognitive abilities.

  • Identification of Health Behaviors: It identifies the individual’s health behaviors, attitudes, and oral health care needs.

  • Foundation for Care Plan: Provides the basis for developing a dental hygiene care plan.

  • Interprofessional Collaboration: Highlights collaboration with medical professionals for comprehensive care.

Completing a Dental Hygiene Diagnosis (DHD)

  • Data Required: A comprehensive DHD necessitates:

    • Biopsychosocial data

    • Extraoral and intraoral examination (EOIO)

    • Occlusion assessment

    • Hard tissue charting

    • Upscale calculus detection.

    • Periodontal assessment including identification of significant risk factors for caries, periodontal disease, and oral cancer as noted in systems like Eaglesoft.

Documentation of Assessments

  • Electronic Record Keeping: Document assessments in platforms like Eaglesoft, Upscale, and through SOAP notes.

Calculus Detection and Plaque Score

  • Assessment tools are utilized to evaluate calculus and plaque scores during clinical evaluations. Ensure accurate documentation of findings.

Treatment Planning Tree

  • Non-Bone Loss Indicators: If there is no radiographic bone loss (RBL) or clinical attachment loss (CAL), with health indicators such as no bleeding on probing (BOP), treatment options include:

    • Preventive care D1110 or D1120 (Prophylaxis).

  • Gingivitis Indicators: If generalized BOP is 30% or greater with clinical attachment levels between 4-5 mm, consider recommending D4346 with re-evaluation periods of 4-6 weeks.

  • Periodontitis Diagnosis: Clinical scenarios including bone loss necessitate more intensive management plans, utilizing CDT codes such as D4341/D4342 and periodic evaluations.

Instructor’s Evaluation of Students DHCP Plan/Treatment Planning

  • DH Care Plan Components:

    • Formulating a dental hygiene diagnosis or problem statement.

    • Establishing patient-focused goals and measurable interventions.

    • Identifying appropriate CDT codes for treatment plans.

    • Planning treatment appointments in sequence.

    • Discussing risks, benefits, alternatives, and possible outcomes of treatment with patients.

Dental Treatment Plan Components

  • Essential Phases of Therapy: Must outline the dental diagnosis and the phases necessary to eliminate or manage disease and promote health.

  • Prognosis: Provide a prognosis based on expected outcomes as Good, Fair, or Poor:

    • Poor Prognosis: Example: A patient suffering from severe periodontitis, significant CAL, advanced bone loss, uncontrolled diabetes, and smoking habits presents a challenging prognosis.

    • Fair Prognosis: A patient with moderate periodontitis who manages oral hygiene reasonably well remains at risk due to irregular dental visits.

    • Good Prognosis: A patient with mild gingivitis and good oral hygiene practices indicates a high likelihood of reversing the condition with regular care.

Interprofessional Collaboration

  • Emphasizes coordinated care across various healthcare disciplines to address holistic patient needs effectively.

Sequence of Dental Hygiene Care Plan Development

  • Linking Care Plan to Diagnosis: Care plans may comprise multiple dental hygiene diagnoses with clear statements regarding problems, causes, and symptoms.

  • Establishing Priorities:

    • Consider Patient Health: Address diagnoses in relation to patient well-being and comfort, potential for simultaneous treatment and chief complaints.

    • Factors Influencing Prioritization:

    • Patient values, beliefs, healthcare provider philosophy, collaborative dentist goals, and patient health status.

Setting Goals

  • Patient-Centered Goals: Should address cognitive, psychomotor, affective domains and relate directly to oral health status.

  • Writing Goals: Formulate goals containing:

    • A subject (the patient)

    • A verb (what will be done)

    • A criterion for measurement (how success is gauged)

    • A time dimension (when evaluation will take place).

Selecting Dental Hygiene Interventions

  • Factors contributing to unmet needs can include:

    • Knowledge deficits

    • Lack of protective factors

    • Skills deficiencies in self-care

    • Valuation of oral health

    • Financial limitations

    • Cultural barriers

    • Presence of other comorbid risk factors.

Appointment Schedule

  • Scheduling Importance: Outlines the proposed interventions, including:

    • Number of visits

    • Duration of each visit

    • Specific interventions to be administered during each appointment.

Care Plan Presentation

  • Involves discussing:

    • The patient's condition

    • The proposed care plan

    • Risks associated with treatment

    • Prognosis if untreated

    • Alternative options available.

Informed Consent

  • Ongoing Process: Informed consent is not just a one-time event but must be continuously updated throughout the care process. The patient must provide consent for:

    • Specific treatments

    • Procedures compatible with legal standards

    • Under truthful conditions

    • Be legally competent.

Informed Refusal

  • Clinician should engage the patient and understand their reasons for declining services. An electronic record of the patient’s informed refusal should be documented in their dental records.

Goal of Evaluation

  • Therapeutic Outcome Documentation: Evaluation is key to documenting the achievement of desired patient outcomes. Evaluation is interlinked with all phases of the dental hygiene care process.

Ongoing Monitoring

  • Evaluation serves as a continual process to:

    • Modify the care plan if patients struggle to achieve goals.

    • Extend time required for goal attainment.

    • Continue care if goals are being met or terminate care once goals are achieved.

Evaluation of Care Plan Goals

  • Determining if dental hygiene care achievements met unmet human needs includes evaluating through:

    • Open-ended questions (for cognitive goals)

    • Technique demonstrations (for psychomotor goals)

    • Patient reports (for affective goals)

    • Clinical health improvements (for oral health status goals).

Evaluation Outcomes

  • Based on evaluation findings, determine:

    • Goal met

    • Goal partially met

    • Goal not met

Modifying or Terminating the Care Plan

  • If minimal progress occurs, re-evaluation of the patient’s readiness, attitudes, beliefs, and practices is necessary. Formulate evaluative statements to assess why a plan may not be successful in achieving defined goals.

Example of Evaluative Statement

  • An evaluative statement example includes the following: "The patient has not successfully achieved the defined goal of reducing gingival inflammation due to inconsistent oral hygiene practices. Despite repeated instruction on proper brushing and flossing technique, plaque accumulation remains evident. Additionally, the patient has missed scheduled periodontal maintenance appointments, contributing to persistent bleeding on probing and continued gingival inflammation."

Dental Hygiene Prognosis and Continued Care

  • Dental Hygiene Prognosis: An evidence-based prediction concerning the patient’s ongoing health and wellness dependent on:

    • Overall evaluative statements appraisal

    • Continued adherence to self-care recommendations

    • Level of oral health achieved.

Documentation

  • Importance of Accurate Documentation: It is crucial for maintaining continuity of care, facilitating communication among interdisciplinary care providers, and minimizing malpractice risks. Documentation must include:

    • All collected data

    • Care plans

    • Consent procedures

    • Treatment outcomes

    • Continuing care recommendations.

SOAPS Documentation

  • Components:

    • Subjective: Contains history and background, chief complaint, medical and dental histories, patient reports, and risk factors.

    • Objective: Recorded observations including vitals, radiographs, screening results, occlusion class findings, hard tissue charting, and calculus data.

    • Assessment: Includes ASA classification, periodontal classification, calculus classification, restorative needs, and overall diagnosis prognosis.

    • Plan: Outlines planned assessments, treatments, and interventions based on evaluations conducted during the appointment.

    • Services: Treatment rendered during the appointment, including instruments used and outcomes achieved.

    • Next Visit: Planned treatments and follow-ups, along with clinician signatures to provide legal documentation.

Common CDT Codes

  • Examples of CDT Codes:

    • D0140: Limited oral evaluation

    • D1120: Child prophylaxis

    • D110: Adult prophylaxis

    • D1206: Fluoride Treatment

    • D0210: Full mouth series radiographs

    • D4341: Quadrant scaling/root planning (4 or more teeth)

    • D4910: Periodontal maintenance