The Dental Hygiene Pen, Part 1 – Effective Time Management With a Commitment to Records Regulations, Standards of Practice, and Ethical Principles –

It may seem as though in our pursuit as dedicated, competent dental hygienists, time may occasionally be lost for documenting the care provided.  Unfortunately, there are instances when the only form of communication that we have with other people is through what we have written down.  Can we accurately say that the quality of our documents is a reliable measure of the quality of the dental hygiene care we provide?  Many people say yes, we can.

On the surface, documentation might seem monotonous, uninteresting, and repetitive in nature.  The significance of what needs to be written down may be unknown for several years.  Perhaps it seems that there might be something more important to do at the moment, such as furthering the client’s oral health knowledge or asepsis management.

Although the topic of dental hygiene documentation is very broad, and a brief blog cannot even begin to convey its significance, I feel a quick look at documentation specifically during the periodontal maintenance appointment is time well spent.

It goes without saying that the client chart needs to reflect the various components of the dental hygiene process of care.  Assessment findings need to be thoroughly documented, both as baseline data and also as periodic updates. The dental hygiene diagnosis and client goal statements drive the dental hygiene care plan, which are also to be recorded.  The implementation procedures must include the time spent (either in minutes or units; fee codes are not an acceptable standard.)  (Remember that dental radiographs are a prescription, much like a medication, are not in the dental hygiene scope of practice; therefore, the prescription must also be written down.)  Oral self care aids and instructions have to be recorded.  Evaluation documentation completes the cycle.

This brings us to the perennial question: how do we record all of this in the client record with limited appointment times?  Perhaps the development of a periodontal maintenance sheet can help.  Preprinted sheets can be utilized that have check boxes or words to circle.  This can speed up the documentation process and also assist with intra- and interprofessional calibration. Preprinted forms require minimal work to develop but can facilitate high quality documentation.

Below is a template example of what might be included in a preprinted periodontal maintenance form, although you can tailor yours to suit your practice needs:

Name:  __________________________________________   Medical Alert: None o or ______________________________
Date:	M.H. Update Changes:  Y oNo ______________		EO:  o WNL or ________________­­­_ IO:  o WNL or _________________ TMJ: o WNL or _________________ OSC Practices: _________________  _________________		Deposits:		L	M	H	OSC: E G F P
Clinician:					Plaque
Time In:	Meds: o none ______________ ______________ ______________ ______________				Supra. Calculus
Time Out:					Sub. Calculus
Consent: o Y oN					Stain
DH DX – Human Needs Deficits: oWholesome Facial Image  oProtection From Health Risks  oFreedom from Anxiety/Stress                                                      o Biologically Sound/Functional Dentition  oResponsibility for Oral Health  oFreedom from Head/Neck Pain  oSkin/Mucous Membrane Integrity of the Head/Neck  oConceptualization/Understanding
Client Goals:	Observations: Client Informed: oY oN			Next Appt. / TX Advised:		OSC Aids Dispensed:                                   otb       ot. paste      ointerdental br.                                  ofloss  ofl. holder   othreader oother: ______________________                      OSC Instructions: _____________________________
Radiographs:                    BWs: oo  oo        FMX/PAs:                           oo  ooo  oo             oo                oo              oo  ooo  oo            PAN: o   CEPH: o    DDS/DMD: __________		Notes:
		Today’s TX Interventions:
Evaluation:							DDS/DMD:

(Some formatting has been lost during posting.)
The above template can be printed twice on each side of an 8 1/2 x 11 inch page.  You might also consider including a periodontal charting record on the reverse.  It’s quick and easy to look back at what transpired during previous periodontal maintenance appointments using a standard and comprehensive format.

A key feature to consider with your documentation is a blank area or section.  A blank area or section can be interpreted as a criterion that was not assessed or completed, so ensure that all areas have some type of notation in them, even if it’s a dash ‘-,’ ‘WNL,’ ‘N/A,’ or ‘none.’ This cannot be overemphasized, especially with regards to identifying features, such as client and clinician names.

Finally, be sure to document throughout the appointment, writing down relevant pieces of information as they arise. For this, I advocate the use of overgloves.

To this end, the purpose here was a bit of a review, sprinkled with perhaps some new information to inspire. In this ever-evolving profession, as we continue to progress in the care we provide, we must upgrade our documentation skills to reflect that progression. 

            I’d love to hear about how you successfully manage your documents.  What works well for you?

Suggested Readings:

1. CDHO Regulations Part III.I - Records  http://www.cdho.org/LegislationAndByLaws/RecordsReg.pdf
2. CDHO Registrant’s Handbook, Chapter 6, Recordkeeping http://www.cdho.org/Practice_RegistrantsHandbook.htm
3. RCDSO Dental Recordkeeping Guideline http://www.rcdso.org/pdf/guidelines/RCDSO_Guidelines_Dental_Recordkeeping_May08.pdf