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Questions and Answers
What must a dental hygienist record?
Quality records as per CDHO regulations.
Where can an RDH find regulations for quality records?
Following the Dental Hygiene Act is optional.
False
What does PIPEDA protect?
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What does PHIPA emphasize?
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Why is maintaining quality dental hygiene records essential?
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How does ethics fit into record keeping?
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Complete and accurate documentation can mitigate legal risks.
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What should all entries be?
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What is an addendum entry?
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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.
