The primary goals of good documentation are to maintain continuity of care, provide a means of communication between/among treating providers, and to minimize the risk of exposure to malpractice claims.
Dental hygiene records are considered legal documents and as such should include:
The complete and accurate recording of all collected data
Treatment planned and provided
Recommendations (both oral and written)
Treatment outcomes and patient satisfaction
Other information relevant to patient care and treatment
Documentation should also include:
I. All components of the dental hygiene process of care (assessment, dental hygiene diagnosis, planning, implementation, and evaluation) including the purpose of the patient’s visit in the patient’s own words. Documentation should be detailed and comprehensive; e.g., thoroughness of assessment (soft-tissue examination, oral cancer screening, periodontal probing, tooth mobility) and reasons for referrals (and to whom and follow-up). Treatment plans should be consistent with the dental hygiene diagnosis and include no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.
II. Objectively record all information and interactions between the patient and the practice (e.g., telephone calls, emergencies, prescriptions) including patient failure to return for treatment or follow through with recommendations.
III. Record legible, concise, and accurate information. For example, include dates and signatures, record clinical information so that subsequent providers can understand it, and ensure that all components of the patient record are current and accurately labeled and that common terminology and abbreviations are standard or universal.
IV. Recognize ethical and legal responsibilities of recordkeeping including guidelines outlined in state regulations and statutes.
V. Ensure compliance with the federal Health Information Portability and Accountability Act (HIPAA). Electronic communications must meet HIPAA standards in order to protect confidentiality and prevent changing entries at a later date. VI. Respect and protect the confidentiality of patient information.
The Standards for Clinical Dental Hygiene Practice are a resource for dental hygiene practitioners seeking to provide patient-centered and evidence-based care. In addition, dental hygienists are encouraged to enhance their knowledge and skill base to maintain continued competence.
The Standards will be modified based on emerging scientific evidence, ADHA policy development, federal and state regulations, and changing disease patterns as well as other factors to assure quality care and safety as needed.