Record Keeping for the Dental Hygienist

1. Record Keeping for the Dental Hygienist Presented by Terri Strawn RRDH, BDScDH

2. DISCLAIMER

3. Agenda • Regulated Health Professions Act • General Guidelines • Dental Hygiene Act, 1991 • Records Regulation • What’s expected working in clinical practice? • What’s expected working in public health? • Storage of Records • Professional Misconduct • Portfolio Layering

4. Regulated Health Professions Act • Legislation that directs all regulated health professions in Ontario. • Includes dental hygiene and dentistry • Includes quality assurance requirements. • http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_91r18_e.htm

5. RHPA Quality Assurance • Co-operation with Committee and assessors • 82.  (1)  Every member shall co-operate with the Quality Assurance Committee and with any assessor it appoints and in particular every member shall, • (a) permit the assessor to enter and inspect the premises where the member practises; • (b) permit the assessor to inspect the member’s records of the care of patients; • (c) give the Committee or the assessor the information in respect of the care of patients or in respect of the member’s records of the care of patients the Committee or assessor requests in the form the Committee or assessor specifies;

6. RHPA Quality Assurance • Inspection of records • (3)  Every person who controls records relating to a member’s care of patients shall allow an assessor to inspect the records. • Exception • (4)  Subsection (3) does not require a patient or his or her representative to allow an assessor to inspect records relating to the patient’s care. • Conflict • (5)  This section applies despite any provision in any Act relating to the confidentiality of health records. 1991, c. 18, Sched. 2, s. 82.

8. General Guidelines • Don’t leave spaces • Write legibly so all can read • Write in ink – a colour that is “photocopyable“ • If electronic records make sure after entries they cannot be edited or are locked • Never alter a chart – make adendums • Sign the chart with your name you are registered under and your designation

9. Dental Hygiene Act, 1991

10. Records Part III.1

11. 9.  (1)  A member shall, in relation to his or her practice, take all reasonable steps to ensure that records are made, used, maintained, retainedand disclosed in accordance with this Regulation. O. Reg. 9/08, s. 1. • (2)  A member shall ensure that his or her records are up to date and made, used, maintained, retained and disclosed in accordance with this Regulation. O. Reg. 9/08, s. 1.

12. 10.  (1)  Subject to subsection (2), a member shall maintain a daily appointment record that contains the name of each client who the member examines, treats or for whom the member renders any service. O. Reg. 9/08, s. 1.

14. Public Health • Where a client is part of a communal screening program, the member shall maintain a daily appointment record that contains, • (a) the information required under subsection (1); or • (b) the name of each client participating in the program, the name of the group each client is associated with and the name of any other member working with the member. O. Reg. 9/08, s. 1.

15. Equipment • 11.  (1)  Each member shall maintain an equipment service record that contains servicing information for any instrument or equipment that is used by the member to examine, treat or render any dental hygiene service to a client. O. Reg. 9/08, s. 1. • (2)  Each member shall maintain a record referred to in subsection (1) in relation to equipment that is used to sterilize equipment or instruments. O. Reg. 9/08, s. 1.

16. Finances • 12.  (1)  Each member shall maintain a financial record for each client, unless the client is a client in a communal screening program, or any other program where there is no payment from or on behalf of a client to the member. O. Reg. 9/08, s. 1. • (2)  A financial record shall contain the treatment or procedure rendered, the fee charged or received, and where available, the record of any receipt issued by or on behalf of the member. O. Reg. 9/08, s. 1.

17. What is expected in our client charts?

18. Clinical Record Keeping • Clinical Records must contain: • (a) the client’s name, address, and date of birth; • (d) the name and address of the client’s primary care provider, if available; • (e) the name and address of the client’s primary care dentist, if available, unless the record is shared with that dentist; • (f) the name and address of any referring health professional;

19. The member shall ensure that every part of a client health record has a reference identifying the client. O. Reg. 9/08, s. 1. • The member shall ensure that every entry in a client health record is dated and includes the identity of the person who made or dictated the entry. O. Reg. 9/08, s. 1.

20. Communication • the date of each professional contact with the client, or the client’s substitute decision-maker, and whether the contact was made in person, telephone or electronically;

22. (g) an appropriate medical and dental history of the client; • must be taken and discussed with the client or the client’s substitute decision maker. • If there is a space for the client and clinician to sign they must be signed. • (h) every written report received by the member respecting examinations, tests, consultations or treatments performed by any other person relating to the client; • (i) a copy of every written communication sent by the member relating to the client; • (j) each examination, clinical finding and assessment relating to the client;

23. Registrants may choose to develop their own charting system or to evaluate an existing system against the Medical/Dental History Guide available on the CDHO web site. • If warranted, and with the client’s consent, further discussion with the appropriate health care professional to receive a medical clearance should occur. • Ideally, the clearance will be provided in writing either by fax or email and included in the client’s chart. • If the information is obtained over the telephone, the registrant should clearly document the substance, time and date of the conversation.

24. CDHO Standards of Practice • Establishing and maintaining communication with other health professionals who are part of the individual client’s circle of care.

25. Chart Form Examples/Downloads • CDHO Medical/Dental History questions - http://www.cdho.org/reference/english/medical_dental_history.pdf • Dental Forms and Documents to Download and print - http://www.drotterholt.com/downloads.html

28. any medication taken by the client as a precondition to treatment or examination by the member for each intervention, including the name of the medication, the time it was taken, and if the medication was not administered to the client by the client, the name of the person who administered it to the client;

29. I’m on a med for BP but can’t remember the name

30. Should not initiate care if… • Ct is taking a drug or a combination of drugs with which the registrant is unfamiliar or which could affect the appropriateness, efficacy or safety of the procedure. • The registrant should further interview the client as to the nature of the medication and effects. • The registrant should research the drug(s) and note any contraindications to proceeding with treatment. If the registrant is in doubt, s/he should consult with the appropriate healthcare provider.

31. Most commonly the pharmacist

33. Dental Hygiene Diagnosis • Prior to care planning you must have determined a clients dental hygiene diagnosis. • Statements that give rationale for your planned interventions. • You do not need to include Darby & Walsh’s Human Needs. • Can include a periodontal diagnosis i.e. gen mod chronic gingivitis as your DH Dx.

34. Dental hygienist can and are expected to dx diseases/disorders within their scope of practice

35. Example • Gen 4 – 5 mm PD With gen mod BOP: gen mod chronic plaque ind. Gingivitis related to Gen mod marg. & ip plaque, gen light subg ledges calc w loc. Mod supra ledges – md ant. • Ineffective tb method (fones) and lack of flossing as evidenced by plaque and calc. buildup and ct. report • HN: Skin and mucous membrane integrity of the head and neck related to petechiae on b mucosa

36. Legend • Md – mandibular • Ant – anterior • TB – toothbrushing • Calc – calculus • Ct – Client • B – buccal • HN – human need • PD – Probing Depths • Gen – generalized • Loc – localized • Mod – moderate • Ind– induced • Marg – marginal • Ip – interproximal • Subg – subgingival • Supra - supragingival

37. Dental Hygiene Care Plan • any dental hygiene treatment plan; • each treatment or procedure performed for each intervention, and the identity of the person applying the treatment if the person applying the dental hygiene treatment was not the member • i.e. if a level II dental assistant was providing oral hygiene instruction, polishing, applying fluoride or placing sealants

38. Remember! • The dental hygiene care plan/treatment plan includes goals/outcomes of care. • Examples: Goal: Pockets >3mm will be reduced by 1mm by next recare. • Goal: client will report a lack of healing (if present) 2 weeks post appt. • Goal: Client will report brushing 2x/day using mod. Bass by next rc. • Client will report flossing 2x/wk by next rc.

39. Example: • Client verbally consented to 1uOSC addressing above, 3u FM sc to remove plaque and disease contributing factors, post care eval 4 – 6 wks. • Or

40. any advice given by the member including any pre-treatment or post-treatment instruction given by the member to the client or the client’s substitute decision-maker; • Example: POI - Rinse with a warm salt-H20 solution (mix ½ tspsalt in 8 oz. warm H20) 2-3 x/day for the next day or two.

41. every controlled act, within the meaning of subsection 27 (2) of the Regulated Health Professions Act, 1991, performed by the member, including the source of the authority to perform the controlled act; • Example: 45 min hand sc. Authorized by Dr. Gingivitis or • 45 min hand sc. SO#2013 or • 45 min hand sc.

42. (p) every referral of the client by the member to any other person;

43. Example

44. every procedure that was commenced but not completed, including reasons for non-completion;

45. a copy of every written consent provided by the client, or the client’s substitute decision-maker; and • every refusal of a treatment or procedure by the client, or the client’s substitute decision-maker. O. Reg. 9/08, s. 1.

46. Informed Refusal Radiographs Example • “I have been advised to have the following radiographs (x-rays) taken as part of a complete and thorough exam, in order to assist in thoroughly diagnosing oral or dental diseases that may be present (some of which can be detected only with radiographs):” • “I understand that by not having the recommended radiographs, conditions may arise at any time in the future that could have been prevented, detected earlier, and treated more successfully and less expensive if the radiographs were taken. These conditions can include tooth decay, gum disease, infections, cysts, and tumors. Not diagnosing them early could result in more pain and discomfort, more expensive treatment, losing teeth that might otherwise be saved, and not detecting growths until they are very large.” • “I am refusing to have these radiographs taken at this time. I therefore release Dr. ____________________ from any and all liability resulting from diseases or pathology, now or in the future, that these radiographs might have revealed.”

47. Oral Hygiene Instruction/Education • Prescription Notepad – CDHO - http://www.cdho.org/docs/default-source/pdfs/reference/prescriptionnotepad.pdf • Oral Health Fact Sheets – ODHA - http://www.odha.on.ca/drupal/node/17 • CDHA Fact Sheets- http://www.cdha.ca/cdha/The_Profession_folder/Resources_folder/Fact_Sheets_and_Resources/CDHA/The_Profession/Resources/Fact_Sheet_and_Resources.aspx

49. For each intervention, the amount of time the member spent providing dental hygiene care; • Oral hygiene education/instruction • Debridement • Selective Polishing • Fluoride application/desensitizing • Irrigation

50. Example • 15 min OSC –demo’dio exam to ct, ct able to identify petechiae, demo’d mod bass brushing and “c-shaped” flossing, ct able to competently demo brushing tech. Modified flossing technique to include use of floss wand. 45 min hand scaling performed. Mod – heavy BOS. Client tolerated procedure well. Post op inst: rinse with warm salt H2O 2 – 3x daily as required.