Podcast
Questions and Answers
What must a dental hygienist record?
What must a dental hygienist record?
Quality records as per CDHO regulations.
Where can an RDH find regulations for quality records?
Where can an RDH find regulations for quality records?
Following the Dental Hygiene Act is optional.
Following the Dental Hygiene Act is optional.
False
What does PIPEDA protect?
What does PIPEDA protect?
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What does PHIPA emphasize?
What does PHIPA emphasize?
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Why is maintaining quality dental hygiene records essential?
Why is maintaining quality dental hygiene records essential?
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How does ethics fit into record keeping?
How does ethics fit into record keeping?
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Complete and accurate documentation can mitigate legal risks.
Complete and accurate documentation can mitigate legal risks.
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What should all entries be?
What should all entries be?
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What is an addendum entry?
What is an addendum entry?
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All client entries should be _____ and signed by the person who performed the procedure.
All client entries should be _____ and signed by the person who performed the procedure.
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Study Notes
CDHO Records Regulations
- The College of Dental Hygienists of Ontario (CDHO) mandates quality record-keeping for Registered Dental Hygienists (RDH).
- The CDHO Registrants Handbook outlines specific standards of practice for record-keeping in Chapter 6.
- The DH Act of 1991 (Part III.I 8-12.4) further legislates mandatory record-keeping requirements.
Privacy & Data Protection
- The Personal Information Protection and Electronic Documents Act (PIPEDA) safeguards personal data for commercial purposes, including dental services.
- The Personal Health Information Protection Act (PHIPA) safeguards sensitive health information, including medical and dental records, emphasizing confidentiality, patient consent, and secure handling.
Benefits of Quality Record Keeping
- Accurate and complete records enable effective communication between healthcare professionals.
- Records document the care provided, allowing for trend analysis in patient health.
- This ensures hygienists meet professional standards and ethical obligations.
- Proper documentation contributes to optimal client outcomes and aligns with CDHO regulations and quality assurance requirements.
Ethical Implications
- Ethics, professionalism, and client advocacy underpin quality record-keeping.
- Accurate entries build trust, foster transparency, and advocate for the client’s best interests.
- By maintaining honest and precise records, DH demonstrate their commitment to integrity and ethical practice.
Legal Standpoint
- Quality record-keeping mitigates legal risks for both the hygienist and the client.
- Complete and accurate documentation serves as a primary defense against legal claims by demonstrating adherence to standards and transparency.
- Inadequate or incomplete records can be used against a dental professional in legal disputes, suggesting negligence or a breach of duty.
Client Record Keeping Principles
- Entries must be legible, accurate, concise, and dated chronologically.
- All entries should be signed digitally by the individual who performed the procedure.
- Client management software (CMS) programs often lock records after signature, preventing alterations.
Why Lock Records?
- Locking records in CMS after the hygienist signs prevents unintended edits.
- By locking, the integrity of the record is preserved, ensuring a reliable and accurate representation of the care provided.
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Description
This quiz covers the record-keeping standards mandated by the CDHO for Registered Dental Hygienists, focusing on Chapter 6 of the Registrants Handbook. It also explores privacy laws such as PIPEDA and PHIPA that protect patient information. Understand the importance of quality record-keeping in dental practices and its implications for patient care.
