law and ethics La Salle 2022 (1).pptx

California Dentistry Law & Ethics Dr. Rosa Eugenia Arzu September 2023 About Me About me (Cont.) Work: • Altamed 4 days • Private Practice 1 day Disclaimer: •I am not an attorney. This presentation is designed to serve as a study guide for those taking the California Dental Law and Ethics Exa...

California Dentistry Law & Ethics Dr. Rosa Eugenia Arzu September 2023 About Me About me (Cont.) Work: • Altamed 4 days • Private Practice 1 day Disclaimer: •I am not an attorney. This presentation is designed to serve as a study guide for those taking the California Dental Law and Ethics Examination and does not constitute legal advice. For legal counsel, consult a qualified attorney. California Dental Law and Ethics •The California Dental Law and Ethics exam is a 50-minute exam consisting of 50 multiple-choice questions. •This information will help you with all your Dental Careers. The exam is composed of questions from two subjects – ethics and law. 34% of the questions are ethical and 66% of the questions are related to law. The ethics portion of the exam assesses the candidate’s ability to comply with ethical standards, including the scope of practice and ethical conduct. The law portion of the exam assesses the candidate’s ability to comply with legal obligations, including patient confidentiality, professional conduct, and information management. 1- California dental practice act Docume nts 2- Your guide to California Dental Practice Act Compliance 3- California Dental Association Code of Ethics 4- Table of Permitted Duties There are 4 terms and definitions you should be familiar with 1.Dentistry 2.Scope of practice 3.Standard of care 4.Patient of record What is Dentistry ? •“Dentistry is the diagnosis or treatment, by surgery or other method, of diseases and lesions and the correction of malpostions of human teeth, alveolar process gums, jaws, or associated structures; and such diagnosis or treatment may include all necessary related procedures as well as the use of drugs, anesthetic agents, and physical evaluation” Scope of Practice •Dentist are licensed to diagnosis and treat diseases and make corrections to the human teeth, alveolar process, periodontium, and associated structures. This includes endodontics, orthodontics, periodontics, oral surgery, and the placement of implants. However, these procedures are only within the dentist’s scope of practice if he or she can perform them completely. Standard of Care •The level of care that a reasonably prudent dentist would exercise under the same or similar circumstances. Patient of Record •A patient of record is a person who has completed a medical history form, has been examined by a licensed dentist and has had oral conditions diagnosed and been provided a written plan that details how these conditions will be treated. California Boards, Committees and Councils 1 The dental Board of California 2 The dental hygiene committee of California (DHCC) 3 Dental assisting Council (DAC) The Dental Board of California • Part of the department of consumer affairs • Main authority regarding the practice of dentistry in CA • Responsible for administering and enforcing the health and safety of consumers in the state of California Composit ion of the dental board of California •8 •4 •1 •1 practicing dentist members of the public registered dental hygienist registered dental assistant Compositio n of the dental hygiene committee of California (DHCC) • • • 1 practicing dentist 4 members of the public 4 registered dental hygienists Dentists (dds or dmd) Classifica tion of Dental Professio nals in California Registered Dental Asistants (RDA) Registered dental Hygienist (RDH) Dental assistants (DA) Registered Dental Assistant in Extended Functions (RDAEF) Registered Dental hygienist in Extended Functions (RDHEF) Obtaining a Dental License in California Licensure by Examination or Residency or Credential - Fingerprint clearance for Department of Justice and FBI - Completion of California Law and Ethics exam Complete application for license insurance and register place of practice. After obtaining a dental license, you must notify the board if: - You change your address An adverse event occurs under your care: Death of a patient during the performance of any dental or dental hygiene procedure The discovery of death of a patient whose death is related to a dental or dental hygiene procedure The admission of a patient to a hospital or emergency center for medical treatment exceeding 24 hours unless otherwise planned or scheduled. Changing your address You must notify the board within 30 days of an address change Adverse event Reporting •An adverse event occurs under your care: • Death of a patient during the performance of any dental or dental hygiene procedure • The discovery of death of a patient whose death is related to a dental or dental hygiene procedure • The admission of a patient to a hospital or emergency center for medical treatment exceeding 24 hours unless otherwise planned or scheduled. •If one of the adverse events listed above occurs under your care, you must notify the board, in writing, within 7 days. License Renewal CALIFORNIA DENTAL LICENSES ARE RENEWED EVERY 2 YEARS. REQUIRES 50 HOURS OF CONTINUING EDUCATION – HALF OF WHICH CAN BE OBTAINED FROM SELF-INSTRUCTION COURSES IT IS YOUR RESPONSIBILITY TO MAINTAIN ACCURATE RECORDS OF THE CE COURSES YOU HAVE COMPLETED What Happens if Your License expires? •If your license were to expire, an expired dental license can be renewed within five years of expiration by paying all accumulated fees and submitting proof that the required CE credits were earned since the license expired. •If the license expired more than 5 years ago, a new application must be filed. Disciplinary Action Types of discipline administered by the dental board: - Revocation Suspension Probation Reprimand Limited Practice - More Training Public Service Restitution Fine Dental Assistants •A dental assistant is an individual who, without a license, may perform basic supportive dental procedures, as authorized by law, under the supervision of a licensed dentist. Basic Supportive Dental Procedure s Defined: •Basic supportive dental procedures are procedures that have technically elementary characteristics, are completely reversible, and are unlikely to precipitate potentially hazardous conditions for the patient being treated. •Does not include procedures authorized only for registered assistants. RDA and RDAEF •A registered dental assistant (RDA)and a registered dental assistant in extended finctions (RDAEF) are licensed individuals who completed additional instruction in order to be able to perform additional procedures. Dental Hygiene Defined: •The practice of dental hygiene includes dental hygiene assessment, development, planning, and implementation of a dental hygiene care plan. It also includes oral health education, counseling, and health screenings. •A dental hygienist may provide, without supervision, educational services, oral health training programs, and oral health screenings. Dental Hygiene Defined: •The practice of dental hygiene does not include any of the following procedures: •Diagnostic and comprehensive treatment planning. •Placing, condensing, carving or removal of permanent restorations •Surgery or cutting on hard and soft tissue including, but not limited to, the removal of teeth and the cutting and suturing of soft tissue. •Prescribing medication •Administration of general anesthesia or oral or parenteral conscious sedation, except for the administration of nitrous oxide and oxygen, whether administered alone or in combination with each other, or local anesthesia. Dental Assisting Speciality Permits •With additional training and examination, DAs, RDAs, and RDAEFs can obtain and orthodontic assistant permit or a dental sedation assistant permit. There are two categorie s of Supervisi on •Direct Supervision •General Supervision Direct Supervision •Direct supervision requires that the dentist provides instructions and is physically present in the facility at the time that the treatment was performed. General Supervision •General supervision means that instructions are given by a licensed dentist who is not physically present in the facility when the treatment is performed. - Endorsed Dental Specialities include: Endodontics Oral-Maxillofacial Surgery Recognized Specialties Oral pathology Orthodontics Pediatric Dentistry Periodontics Public Health Limiting your Practice •Without specializing, you can publicly state that you: •Limit your practice to some field or that you are certified by a private or public board or agency to complete said procedure. Sedation •Conscious sedation is defined as a minimally depressed level of consciousness produced by a pharmacologic or nonpharmacologic method that retains the patient’s ability to independently maintain an airway and respond to physical stimulation and verbal commands. • When can you provide confidential information without authorization? Confidentiali ty and HIPAA • All of your patients must be given notice of your privacy practices and the patient must get an opportunity to review the document before signing. Dental Records •The doctor owns the records and the patient has the right to access complete information regarding their condition and care •A patient has the right to ask about, read, see, ad obtain a copy of their records. •You must maintain each patient’s records for at least seven years after the completion or termination of treatment. You must also keep the records for seven years after the patient turns 18. Informed Consent •Informed consent is a process of interaction, communication, and education that is supplemented by documentation. •Informed consent includes the diagnosis, the proposed treatment, the risks, benefits, and alternatives to the proposed treatment including the potential side effects and costs. •Patients must be informed using a language they understand. Advertising and Marketing Advertising is defined as any written or printed communication for the purpose of soliciting, describing, or promoting a dentist’s licensed activities; any directory listing; any radio, television, or electronic transmission that promotes the dentist’s practice; any printing or writing on novelty objects or dental care products. Marketing does not include any printing or writing used on buildings or uniforms to identify the dentist’s practice. Advertising and Marketing It is unlawful for any licensed dentist to make false fraudulent, misleading, or include deceptive statements, images, or claims in his or her advertisement(s) You cannot use images of a model (anyone other than an actual patient of the advertising dentist) without clearly stating in an easily readable type that the image is of a model and not an actual patient. Advertising and Marketing It is unprofessional to advertise a guarantee that any dental service will be performed painlessly A dentist shall not compensate or give anything of value to a representative of the press in return for a publicity unless the fact of compensation was received in exchange for the publicity is made known in the publicity. Random Knowledge Dental Materials fact Sheet Telehealth Acupuncture Sexual harassment Mandatory Reporting Dental Materials Fact Sheet •You must provide each patient with a dental materials fact sheet prior to completing any restorative work. •Patients must sign a form acknowledging that they have had an opportunity to review the dental materials fact sheet. This signed form should be kept within the patient’s record. Telehealt h •Telehealth is the mode of delivering healthcare and public health services via technology while the healthcare provider is at a distant site. Acupunct ure •A licensed dentist, or group of dentists, or a dental corporation shall not share in any fee charged by a person for performing acupuncture or receive anything of value from or on behalf of such acupuncturist for any referral diagnosis. •A licensed dentist shall not employ more than one person to perform acupuncture services and a group of dentists or a dental corporation shall not employ more than one person to perform acupuncture services for every twenty (20) dentists in such group or corporation Sexual Harassm ent •Sexual harassment is any unwelcome sexual attention •Sexual contact or relations with a patient constitutes professional misconduct •In general, physicians and dentists should not treat themselves or members of their immediate family. Mandatory Reporting •Dentists are required to report suspected child abuse. In California, any practitioner who has knowledge or observes a child whom they reasonably suspect has been the victim of child abuse must report this abuse to a child protection agency immediately by telephone and send a written report within 36 hours •Dentist are also required to report suspected cases of domestic violence •Dentist are also required to report suspected cases of abuse or neglect of an elderly or developmentally disabled patient Code of Ethics 1- Autonomy 2- Beneficence 3- Compassion Definitio ns 4- Competence 5- Integrity 6- Justice 7- Professionalism 8- Tolerance 9- Veracity Autonom y Patients have the right to determine what should be done with their own bodies. Benefice nce The obligation to benefit others or to seek their good. Compassi on The ability to identify and care about the patient’s overall wellbeing. Competenc e •A competent dentist is able to diagnose and treat the patient’s oral health needs and to refer when it is in the patient’s best interest. Integrity To behave with honor and decency. Profession alism Self-governance is the hallmark of a profession. Tolerance Dentists often practice in complex cultural and ethnically diverse communities. Cultural differences exist and dentist are expected to understand how these differences may affect patient choices and treatment. Veracity To be Honest. Lunch Time… Welcome Back! Disclaimer: The California Dental Association Code of Ethics is similar to the American Dental Association Code of Ethics. Before taking the California Dental Law and Ethics Exam, *Read the CDA Code of Ethics in full prior to your test. Table of Permitted Duties Multiple questions on the examination will test your knowledge regarding the scope of practice for: • Registered • Registered functions • Registered practice • Registered functions • Registered dental hygienists dental hygienists in extended dental hygienists in alternative dental assistants in extended dental assistants • Dental assistants • Orthodontic Assistant * • Dental Sedation Assistant * Patient Records and Health Information Portability and Accountabil ity Act (HIPAA) •Under HIPAA, personally identifiable information includes patient’s names, addresses, dates of birth, social security numbers, and medical diagnoses (any information that can be used to identify, locate, or contact an individual). •HIPAA states that HIPAA covered entities must take reasonable steps to limit the use and disclosure of patient health information to the minimum necessary to accomplish the intended purpose. Patient Records and Health Information Portability and Accountabil ity Act (HIPAA) •Use and disclosure of patient information requires patient pre-authorization unless the information is to be used for the continuing care of the patient. •HIPAA does not prohibit the removal of patient information from a healthcare provider’s facility, but the provider is required to have a policy that either allows or prohibits such removal. Patient Records and Health Information Portability and Accountabil ity Act (HIPAA) Expectations: • Providers and Staff that have access to the patient’s chart should not leave the patient record unattended (if leaving the room: log off or leave in sleep mode) Patient Records and Health Information Portability and Accountability Act (HIPAA) In a Dental Office, Who is Responsibl e for PHI Privacy and Security? Everyone working in the office is responsible for maintaining the privacy and security of PHI. What Happens When Patient Informati on is Stolen? •Theft is a crime. If a dentist were to discover that patient records have been taken from his or her office, the next step is to contact local law enforcement. •If the breach affects less that 500 patients, a dental office needs to report the theft to local law enforcement and inform the patients affected of the breach in writing (first class mail or email). No more than 60 days after the calendar year that the breach occurred, the dentist must file a report or breach log to the Office for Civil Rights. What Happens When Patient Informati on is Stolen? •If a breach affects more than 500 patients, a dental office needs to notify the patients in writing, and a copy of the letter must be sent to the state Attorney General’s office. You will also need to notify the US Department of Health and Human Services (HHS) and prominent media outlets. Notification to HSS and media outlets must occur no later than 60 days after the discovery of the breach. No more than 60 days after the calendar year that the breach occurred, the dentist must file a report or breach log to the Office for Civil Rights. Patient Records A Patient of Record •A patient of record is a person who has completed a medical history form, has been examined by a licensed dentist, and has had oral conditions diagnosed and been provided a written plan that details how these conditions will be treated. Dental Record • It contains information about the patient’s treatment plan and care that has been delivered. • Dental records are especially important when submitting dental benefit claims or responding to lawsuits. While the dental record could be viewed as a form of insurance for your practice, make sure you include only those facts that are relevant to providing dental care. • Follow the record-keeping format you establish stringently and always keep in mind that what you write in the record could be read aloud in a court of law. After all, the patient record is a legal document. Dental Record • You, the dentist, is responsible for the codes selected and documented in the patient record and billing systems. • No matter who enters the information, you must make sure all of the information, including any procedure codes referenced, is correct. • Follow the allowable frequency for the code (based on the insurance) • Example (Medi-Cal Dental insurance: • D0150 Comprehensive Oral Exam • D0120 (3-20 years: 6 months; 21 and over: every year) • D0145: 0-3 years every 3 months Dental Record • • Whoever performs the treatment should document it in the record. • All entries should be initialed or signed even if you are the only person who makes an entry in the patient record. Informatio n typically noted in the dental record includes: • Personal data, such as the patient’s name, birth date, address and contact information including home, work and mobile telephone numbers • The patient’s place of employment • Medical and dental histories, notes, and updates • Progress and treatment notes • Reps of conversations about the nature of any proposed treatment, the potential benefits and risks associated with that treatment, any alternatives to the treatment proposed, and the potential risks and benefits of alternative treatment, including no treatment. Include conversations that took place in the office, Informatio n typically noted in the dental record includes: • Diagnostic records, including charts and study models • Medication prescriptions, including types, dose, amount, directions for use and number of refills • Radiographs • Photographs • Intraoral photographs • Treatment plan notes • Patient complaints and resolutions Welcome Back! Day 2 Informatio n typically noted in the dental record includes: • Referral letters and consultations with referring or referral dentists and/or physicians • Patient noncompliance and missed appointment notes • Follow-up and periodic visit records •• • Postoperative or home instructions, or a notation about any pamphlets or reference materials provided • Informed consent/refusal forms • Waivers and authorizations • Correspondence, including a dismissal letter; if appropriate Informatio n that should NOT be noted in the dental record includes: • Personal opinions or criticisms. While it is okay to document a patient’s refusal to accept the recommended treatment plan and information about canceled appointments, be aware that disparaging comments and even informal notes written in the margins of a patient’s chart must be shared if a lawsuit is filed. • Keep patients’ personal information in a location separate from their medical and dental records. Collecting that information on a separate form will make it easier to maintain separate files. Encourage team members to note Ownership of Records - THE DENTIST OWNS THE RECORDS AND THE PATIENT HAS THE RIGHT TO ACCESS COMPLETE INFORMATION REGARDING THEIR CONDITION AND CARE. A PATIENT HAS THE RIGHT TO ASK ABOUT, READ SEE AND OBTAIN A COPY OF THEIR RECORDS. Editing Records A patient cannot add to or edit the dentist’s entries. A patient can request that an amendment be made to their records If a dentist determines that an entry was made in error, an addendum can be made but do not erase the original entry If using a paper chart, do not erase errors, simply make a single-line strikeout Example of a strikeout Initial and date all changes Patient Amendments - If a patient wants to amend their records, they must submit a written request for amendment. The dentist has 60 days to decide to grant or deny the patient’s request to amend the record. - California law allows these amendments to be added to the chart as a statement. These statements can be no longer than 250 words for each item that is believed to be incomplete or inaccurate. Right to Inspect Records •A patient or a patient’s representative has the right to inspect the patient’s records. The inspection of the records should take place during business hours and within five (5) working days of receiving the request. Right of Copy Records •A patient or patient’s representative has the right to receive a copy of the dentist’s information as well as to direct the copy to another individual or entity. A dental practice must provide a copy within 15 calendar days of receiving the request for access. Right of Copy Records •If a patient or patient’s representative asks for a summary of the patient’s records, the summary of the record shall be made available to the patient within 10 working days of the request. If the patient record is large, and more time is needed, an extension is possible, but the summary must be provided within 30 days of the request. Minors • A minor patient may not access his or her record unless: • A parent or legal guardian has authorized access. • The minor is an emancipated minor. Deleting Entries Under federal and CA state law, information may not be removed from a patient’s record under any circumstance. Corrections can be made but erasing information previously entered into a patient’s chart is not acceptable. Oral Health Care Professio nals • Dentists are allowed to provide other dentists or healthcare professionals access to patient information without patient authorizations if the purpose of the information is to coordinate treatment • Example would be sending radiographs to an oral surgeon that accompany the referral. Dental Board of Californi a The Dental Board of California has the authority to inspect or copy patients’ records. Coroner • Dentist must provide information upon a coroner’s request to help identify the deceased, locate next of kin, or investigate deaths. Subpoena • If you receive a subpoena for patient records, contact your attorney immediately. Do not try to impede law enforcement’s access to records. Why Do You Need One? • Patient Record Assist in providing the best possible care for the patient As a means of communication between the treating dentist and any other doctor who will care for that patient. It can be used in defense of allegations of malpractice. Aid in the identification of a dead or missing person. Complete Records Include: Database Place of employment and telephone numbers (home, work, mobile) Medical and dental histories, notes and updates Progress and treatment notes Conversations about the nature of any proposed treatment The potential benefits and risks associated with that treatment Any alternatives to the treatment proposed The potential risks and benefits of alternative treatment, including no treatment information, such as name, birth date, address, and contact information Diagnostic records, including charts and study models Complete Records Include: Full Periodontal Charting Medication prescriptions, including types, dose, amount, directions for use and number of refills Radiographs Treatment plan notes Patient complaints and resolutions Laboratory work order forms • Comple te Records Include: Mold and shade of teeth used in bridgework and dentures and shade of restorative material Referral letters and consultations with referring or referral dentists and/or physicians Patient noncompliance and missed appointment notes Follow-up and periodic visit records Postoperative or home instructions Consent forms Waivers and authorizations Conversations with patients dated and initialed (both in-office and on telephone, even calls received outside the office) Correspondence, including dismissal letter; if appropriate What not to include in the Patient Record? No financial information should be kept in the dental record Ledger cards Insurance benefit breakdowns Insurance claims Payment vouchers Keep these financial records separate from the dental record. the dentist is ultimately responsible for the patient’s chart Some entries may be delegated to office staff The administrative assistant can record telephone calls Cancelled or Changed or failed appointments • Who Makes Entries in the Record? What about the DA? Records the patient’s comments Concerns and disposition Radiographs and other diagnostic tools taken and used Vital signs; medical history notations; Instructions given to the patient, etc Clinical impressions Dentist responsibilities Treatments performed Any pertinent information. Dentist does not have the time: He/she should dictate what to write to the assistant. The dentist should review the contents of the entry as soon as possible for accuracy Sign or initial it. Do not forget. Use of Abbreviations and Acronyms Have a universal “key” readily available to all staff, or included in the chart, providing definitions for all abbreviations and acronyms Corrections or Alterations Cross out • cross out the wrong entry with a thin line, and make the Appropriat • appropriate change. e Date and initial • Date and initial each change or addition. Obliterate • Never obliterate an entry. Do not use • Do not use markers or white-out. Dental Record • Don’t…. Do not leave blank lines between entries with the intent to add something at a later date. Do not insert words or phrases in an entry This could be construed as an alteration. Number One reason a Dentist loses a Case? Errors or inadequacies in the patient record Informed Consent Provides information to the patients about the dental health problems The nature of any proposed treatment The potential benefits and risks associated with that treatment Any alternatives to the treatment proposed, The potential risks and benefits of alternative treatments Including no treatment. Inform the patient about the consequences of not Informed Refusal accepting the treatment and get a signed informed refusal However, obtaining an informed refusal does not release the dentist from the responsibility of providing a standard of care Classic Patient Refusal X-RAYS PERIODONT AL PROBING ROOT PLANING EXTRACTIO NS REFERRALS Periodontal Probing It is part of the comprehensive dental examination . The absence of that information in the chart might be construed as failure to conduct the periodontal examination. Current standards call for full-mouth periodontal probing at each hygiene recall visit Provides record of the patient’s current condition Comparison of any future changes in the patient’s periodontal health. • The date of the examination Periodontal Probing: At a minimum, the documentation should include: • All pocket depths, including those within normal limits • Description of gingival tissue health • Identification of areas of tissue pathology (such as inadequately attached gingiva) • Areas of bleeding or other pathology noted on probing (e.g. suppuration and tooth mobility) If patient refuses periodontal probing, describe and document the risks of refusal to the patient. Consider withdrawing from care if the patient continually refuses periodontal probing. Vicarious Liability • Is the legal responsibility that occurs when one Party is liable for the actions of another Party • Practice owners have a vicarious liability and responsibility for • The credentials • Licensing • Competency of any associates, partners, or independent contractors who treat patients. An example of vicarious liability involves practice partners. A partner’s assets are vulnerable for any acts that his or her partner may conduct when treating patients. This can occur when a patient sues both partners and one partner has never seen a specific patient or participated in that patient’s care Another form of vicarious liability •When a dentist refers a patient to another dentist for an evaluation. •Once a dentist takes on the obligation and duty of rendering dental care and attention, he or she is not released of that duty by delegating to others. The dentist is generally referring to another dentist with greater knowledge in a particular area. Negligen t Referral • If the referral dentist performs his or her duty incorrectly the original referral dentist could be responsible for sending the patient in the first place. Vicarious Liability For acts done by the employee If an assistant or hygienist gives erroneous advice resulting in an injury to a patient, the dentist may be liable. Generally, if the staff person is acting outside the scope of his or her job description or license without the dentist’s knowledge, the dentist may avoid liability. However, if a dentist conducts him or herself in a way that leads patients to believe the staff person is acting within the dentist’s authority, the dentist may be held liable. Dentists should know the specialists to whom they are referring. How they react to unclear recommendations How they communicate with the referring dentist after the treatment is completed. When referring a patient to another office inform the patient the reason for the referral and available alternatives The dentist should write the referral letter and not delegate the task to a staff member It is the referring dentist’s responsibility to follow up (preferably in writing) with referral practitioners and the patients themselves, regarding the status and progress of each referral Rationale for referring for additional treatment: • Level of training and experience of the dentist • Extent or complexity of treatment • Medical complications • Behavioral concerns • Patient preference Write in the chart • Why and to whom was the patient referred? • Did the patient agree to the referral? • What is the time frame for the referral? • Did the patient follow through with the referral? • When was the treatment completed? Advantages: Provides a summary of findings and/or treatment to ensure all treating dentists maintain continuity of care for a patient they are treating. Conclusion When a patient or representative requests access to their records do not intentionally delay their access. Do not edit records with an intent to deceive. Dental Record • The accuracy of the clinical note is the responsibility of the treating provider. • The dental Record is a legal document and should not be altered in any way that could be interpreted as intending to deceive. REMEMBER: • IF IT IS NOT DOCUMENTED IT DID NOT HAPPEN… Dental Record • Treating provider (Dentist or RDH) should complete their own clinical notes. In some situations, this task can be delegated to lower license levels under the supervision of the treating provider. If a DA, RDA, or RDAEF is tasked with writing your note or completing a template after each patient, the dentist should review the note and add his or her initials and license number at the conclusion of the note (EDR: “cosign”). Informed Consent •Informed consent should always be obtained in writing. For minor patients, consent can only be granted by parents or legal guardians unless that authority has been officially transferred. If the parent or legal guardian is unable to provide written consent, treatment should be postponed until written consent can be obtained, unless it is unsafe to postpone treatment. Informed Consent Should Include: •The nature of the recommended treatment. •The risks, benefits, and possible complications of recommended treatment including the likelihood of success. •The alternatives to the recommended treatment which almost always includes performing no treatment. •An explanation of the treatment plan’s expected sequence of events. Informed Consent •Is a process that is complimented by a signed form. Informed consent involves a face-to-face discussion between a dentist and the patient or in the case of minors, between a dentist and the parent or legal guardian. The discussion should not be rushed and should be conducted with sufficient time to address all of the patient or parent’s questions and concerns. Informed consent should be document in the patient’s record. The documentation of informed consent should include the date, parties present, issues discussed, nature of treatment and the risks, benefits, and alternatives to any recommended treatment. Informed Consent Divorces can present challenges to obtaining informed consent and the release of a minor’s records. When parents of a minor are divorced but share custody, it is not always obvious who is responsible for decisions regarding the patient’s oral health. When joint-custody is granted, it is reasonable for dentist to request that the parents decide which one of them will be designated as the parent responsible for both financial and treatment decisions. This designation should be documented in writing and included in the patient’s file. Informed Consent When one parent has legal custody and the other does not, it is sufficient to obtain informed consent from the parent who maintains custody of the child. A step-parent cannot provide consent unless the stepparent has adopted the child or secured legal guardianship. Step-parents without legal guardianship do not have the right to obtain a copy of a minor’s dental records regardless of whether they provided dental benefits (insurance or payments) to the child. If a stepparent has provided dental benefits to the child, they are allowed to access financial records pertaining to the child’s treatment at your office. Unaccomp anied Minors •After an initial exam is completed and informed consent is obtained from a parent or guardian in writing, minor patients can present to a dental appointment without a parent or guardian. However, if a parent or guardian is not present during treatment, the treating dentist should use caution not to perform any treatment that goes beyond the scope of the prior consent. Unaccompa nied Minors •In general, a parent has the right to access his or her child’s dental record regardless of custody status or financial responsibility. It is only permissible for a dentist to deny a parent access to a child’s dental record if the dentist determines that providing such access may harm the patient. In addition, some health information can only be shared with the minor’s consent. Health informatio n that a minor must provide consent to share: •Pregnancy. •Mental health. •Sexual assault. •HIV/AIDS status •Drug or alcohol abuse. •Sexually transmitted disease. •Infectious and communicable diseases. Caretakers • Are allowed to bring minor patients to their dental appointments if an Authorization for a Caretaker to Accompany a Minor form is obtained from the parent or legal guardian in advance. • Can be adult siblings, aunts, uncles, grandparents, or another third party. Lunch Time… Welcome Back!  A self-sufficient minor is under the age of 18 and is either married or divorced, on active duty with the U.S. Armed Forces, or legally emancipated through the court system. Typically, selfsufficient minors live separate and apart from their parents or guardians and manage their own financial affairs. Mandator y InformedConsent when Prescribin g Opioids to Minors: •Before a dentist issues the first prescription of a controlled substance staining an opioid to a minor, the dentist must discuss the following with the minor or the minor’s parent or guardian: • The risks of addiction and overdose associated with opioids. • The increase risk of opioid addiction to individuals who are suffering form both mental and substance abuse disorders. • The danger of taking an opioid with central nervous system depressants including alcohol and benzodiazepines. Evidence-Based Clinical Practice Guideline on Antibiotic Use for the Urgent Management of Pulpal- and PeriapicalRelated Dental Pain and Intraoral Swelling: A Report from the American Dental Association Evidence-Based Clinical Practice Guideline on Antibiotic Use for the Urgent Management of Pulpal- and PeriapicalRelated Dental Pain and Intraoral Swelling: A Report from the American Dental Association •Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. •Is the systematic effort to educate and persuade prescribers of antimicrobials to follow evidence-based prescribing, in order to stem antimicrobial overuse, and thus antimicrobial resistance. Antibioti c Stewards hip Antibiotic Stewards hip Antibiotic Stewardship Antibiotic Prophylaxi s •VIDEO: https://www.youtube.com/watch?v=u3OCkyqI9YA&t=5s How can I practice antibiotic stewardshi p? •VIDEO: https://www.youtube.com/watch?v=u3OCkyqI9YA&t=5s Welcome Back! Day 3 Botox: •Elective Cosmetic Surgery Permits - Licensed Dentists •Business and Professions Code, Section 1638.1, states a person licensed pursuant to Section 1634 who wishes to perform elective facial cosmetic surgery shall first apply for and receive a permit to perform elective facial cosmetic surgery from the board. •Applying for an Elective Cosmetic Surgery Permit •The primary requirements for a permit to perform Elective Facial Cosmetic Surgery are defined in Business and Professions Code, Section 1638.1. •The Committee recommends that the applicant first choose either Pathway A or Pathway B by which the application is being made. Botox: •Pathway A: The requirements for an Elective Facial Cosmetic Surgery Permit include, but may not be limited to submitting the following documentation: 1. A completed application form. 2. Proof of successful completion of an oral and maxillofacial surgery residency program accredited by the Commission on Dental Accreditation of the American Dental Association. 3. Proof of certification, or a candidate for certification, by the American Board of Oral and Maxillofacial Surgery. 4. A letter from the program director of the accredited residency program, or from the director of a post-residency fellowship program accredited by the Commission on Dental Accreditation of the American Dental Association stating that the licensee has the education, training, and competence necessary to perform the surgical Botox: Submit to the board of at least 10 operative reports from residency training or proctored procedures that are representative of procedures that the licensee intends to perform. The Committee recommends that you submit no more than 30 operative reports. Applicants may request that their permit be limited to specific categories of procedures (Category I and/or II), as specified on the application. As a result, operative reports submitted should be reflective and supportive of the permit category for which the applicant is applying. In addition, operative reports should be clear and dark enough to be reproduced. The Committee recommends that the applicant organize the reports submitted, grouping the procedures by category I and category II and provide the Committee with an index of the reports. A sample index is available. Submitting the operative reports in an organized way will ensure the application process moves along quickly. 6. Documentation showing the surgical privileges the applicant possesses at any licensed general acute care hospital and any licensed outpatient surgical facility in this state. 7. Proof that the applicant is on active status on the staff of a general acute care hospital and maintains the necessary privileges based on the bylaws of the hospital to maintain that status. 5. Botox: Pathway B: The requirements for an Elective Facial Cosmetic Surgery Permit include, but may not be limited to submitting the following documentation: 1.A completed application form. 2.Proof of successful completion of an oral and maxillofacial surgery residency program accredited by the Commission on Dental Accreditation of the American Dental Association. 3.Submit to the board of at least 10 operative reports from residency training or proctored procedures that are representative of procedures that the licensee intends to perform. The Committee recommends that you submit no more than 30 operative reports. Applicants may request that their permit be limited to specific categories of procedures (Category I and/or II), as specified on the application. As a result, operative reports submitted should be reflective and supportive of the permit category for which the applicant is applying. In addition, operative reports should be clear and dark enough to be reproduced. The Committee recommends that the applicant organize the reports submitted, grouping the procedures by category I and Botox: 4.Proof that the applicant has been granted privileges by the medical staff at a licensed general acute care hospital to perform the surgical procedures [cosmetic contouring of the osteocartilaginous facial structure, which may include, but is not limited to, rhinoplasty and otoplasty and/or cosmetic soft tissue contouring or rejuvenation, which may include, but is not limited to, facelift, blepharoplasty, facial skin resurfacing, or lip augmentation], at that hospital. 5.Proof that the applicant is on active status on the staff of a general acute care hospital and maintains the necessary privileges based on the bylaws of the hospital to maintain Botox: The California Dental Practice Act permits the use of Botox and other appropriate products for cosmetic procedures only when used as part of a comprehensive dental treatment plan and for one of the purposes defined in section 1625 of the Business and Professions Code. Only oral surgeons who hold an elective facial cosmetic surgery permit in California can provide Botox and dermal filler injections for standalone cosmetic services. General dentists should confirm the scope of their license prior to taking courses that teach Botox-related procedures used in cosmetic dentistry. Botox: The California Dental Practice Act permits the use of Botox and other appropriate products for cosmetic procedures only when used as part of a comprehensive dental treatment plan and for one of the purposes defined in section 1625 of the Business and Professions Code. Only oral surgeons who hold an elective facial cosmetic surgery permit in California can provide Botox and dermal filler injections for standalone cosmetic services. General dentists should confirm the scope of their license prior to taking courses that teach Botox-related procedures used in cosmetic dentistry. Botox: California-licensed general dentists are not permitted to offer Botox and dermal filler injections to patients for purely cosmetic purposes. Only oral surgeons who hold an elective facial cosmetic surgery permit can provide these products for stand-alone cosmetic services. General dentists who offer Botox solely for the purpose of cosmetic enhancement are performing dentistry outside their scope of practice and should refrain from advertising Botox services in their practice and thereby misleading consumers about the availability of Botox for cosmetic purposes alone. The Dental Board of California clarified the allowable use of Botox in April 2019, at CDA’s request, and there is no movement in California to change the scope of cosmetic dentistry. Fictitious Business Names •Dentists who practice under a name other than the name under which they are licensed, must have obtained a fictitious name permit from the Dental Board. Dentists operating with a fictitious name permit issued by the Dental Board must also comply with California State’s requirement that all for-profit businesses that use a fictitious business name need to file a fictitious business name statement with the clerk of the county where the business is located. Rules for Storing and Disposing of Controlled Substance s •Drug Enforcement Administration(DEA) registration is required for each address where a dentist stores controlled substances. • A dentist who stores controlled substances must maintain a log for no less than 3 years and take inventory at least once every 2 years. • Controlled substances must be stored in either a safe, vault, or a steel cabinet. Dentists must dispose of expired, damaged, or otherwise unusable or unwanted controlled substances using a reverse distributor. Mandated Reporting All professionals licensed by the Dental Board of California are considered “mandated reporters”. A mandated reporter is required to report to local law enforcement or a local services agency if the mandated reporter knows, observes, or suspects that a patient (a child or dependent adult) has been a victim of abuse or neglect. To issue a report, begin by calling either your county’s department of child protective services or adult protective services or local law enforcement. A written report must be submitted as soon as practically possible but no later than 36 hours after making the initial verbal report (phone call). Note that HIPAA and state privacy laws do no prevent a mandated reporter for fulfilling their obligation to report abuse. Also note that the pregnancy of a minor is not a basis for reasonable suspicion of sexual abuse on its own. Treatment Accessibility DENTISTS MUST MAKE REASONABLE ARRANGEMENTS FOR EMERGENCY CARE FOR THEIR PATIENTS OF RECORD TO AVOID BEING ACCUSED OF PATIENT ABANDONMENT. FOR EXAMPLE, IF YOU PLAN ON GOING ON VACATION OR TAKING A LEAVE OF ABSENCE FROM YOUR DENTAL PRACTICE, CONTACT A LOCAL COLLEAGUE AND ARRANGE FOR TEMPORARY EMERGENCY COVERAGE FOR YOUR PATIENTS OF RECORD. Treatment •In this Accessibility situation, while you are on vacation, you should update your answering machine to include instructions on how a patient can contact either yourself or a colleague who agreed to provide emergency coverage during your absence. If you contract with an answering service, instruct the operator to collect the patient’s information and forward that information to the dentist who agreed to provide emergency coverage for your patients. In this scenario, it is important to have a method in place for your colleague to be able to verify your patients of record during your Treatment Accessibility •If contacted by a person who is not a patient of record, dentists are still required to make arrangements for the care of the patient. Under such circumstances, a single consultation does not make this person a patient of record. If contacted by a person who is not a patient of record, it is appropriate to: • Prescribe an appropriate analgesic and recommend that the patient schedule an examination (this would be a recommendation or a prescriptions for an OTC analgesic such an an NSAID or acetaminophen – do not prescribe or recommend a narcotic analgesic). • Advise the patient to report to an emergency room or urgent care facility for evaluation (after hours). • Advise the patient to schedule an appointment at your dental office as soon as possible. Infection Control As a dental student or practicing dentist you should be aware of standard infection control policies and procedures. The Board requires that every licensed dental professional in California (DDS, DMD, RDH, RDA, etc.) complete a 2-hour dental continuing education course in "Infection Control" Infection Control course during each 2-year license renewal period. Infection Control • A dental office is responsible for the health and safety of both their patients and their staff. Staff safety falls under the Occupational Safety and Health Administration (OSHA). Infection Control TITLE 16. PROFESSIONAL AND VOCATIONAL REGULATIONS DIVISION 10. DENTAL BOARD OF CALIFORNIA CHAPTER 1. GENERAL PROVISIONS APPLICABLE TO ALL LICENSEES ARTICLE 1. GENERAL PROVISIONS Section 1005. Minimum Standards for Infection Control (a) Definitions of terms used in this section: (1)“Standard precautions” are a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure, and safe handling of sharps. Standard precautions shall be used for care of all patients regardless of their diagnoses or personal infectious status. (2) “Critical items” confer a high risk for infection if they are contaminated with any microorganism. These include all instruments, devices, and other items used to penetrate soft tissue or bone. (3) “Semi-critical items” are instruments, devices and other items that are not used to penetrate soft tissue or bone, but contact oral mucous membranes, non-intact skin or other potentially infectious materials (OPIM). Infection Control (5) “Low-level disinfection” is the least effective disinfection process. It kills some bacteria, some viruses and fungi, but does not kill bacterial spores or mycobacterium tuberculosis var bovis, a laboratory test organism used to classify the strength of disinfectant chemicals. (6) “Intermediate-level disinfection” kills mycobacterium tuberculosis var bovis indicating that many human pathogens are also killed. This process does not necessarily kill spores. (7) “High-level disinfection” kills some, but not necessarily all bacterial spores. This process kills mycobacterium tuberculosis var bovis, bacteria, fungi, and viruses. (8) “Germicide” is a chemical agent that can be used to disinfect items and surfaces based on the level of contamination (9) “Sterilization” is a validated process used to (10) “Cleaning” is the removal of visible soil (e.g., organic and inorganic material) debris and OPIM from objects and surfaces and shall be accomplished manually or mechanically using water with detergents or enzymatic products. (11) “Personal Protective Equipment” (PPE) is specialized clothing or equipment worn or used for protection against a hazard. PPE items may include but are not limited to, gloves, masks, respiratory devices, protective eyewear and protective attire which are intended to prevent exposure to blood, body fluids, OPIM, and chemicals used for infection control. General work attire such as uniforms, scrubs, pants and shirts, are not considered to be PPE. Infection Control (12) “Other Potentially Infectious Materials” (OPIM) means any one of the following: (A) Human body fluids such as saliva in dental procedures and any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. (B) Any unfixed tissue or organ (other than intact skin) from a human (living or dead). (C) Any of the following, if known or reasonably likely to contain or be infected with human immunodeficiency virus (HIV), hepatitis B virus (HBV), or hepatitis C virus (HCV): 1. Cell, tissue, or organ cultures from humans or experimental animals; 2. Blood, organs, or other tissues from experimental animals; or (13) “Dental Healthcare Personnel” (DHCP), are all paid and non-paid personnel in the dental healthcare setting who might be occupationally exposed to infectious materials, including body substances and contaminated supplies, equipment, environmental surfaces, water, or air. DHCP includes dentists, dental hygienists, dental assistants, dental laboratory technicians (in-office and commercial), students and trainees, contractual personnel, and other persons not directly involved in patient care but potentially exposed to infectious agents (e.g., administrative, clerical, housekeeping, maintenance, or volunteer personnel). (b) All DHCP shall comply with infection control precautions and enforce the following minimum Infection Control (1) Standard precautions shall be practiced in the care of all patients. (2) A written protocol shall be developed, maintained, and periodically updated for proper instrument processing, operatory cleanliness, and management of injuries. The protocol shall be made available to all DHCP at the dental office. (3) A copy of this regulation shall be conspicuously posted in each dental office. Personal Protective Equipment: (4) All DHCP shall wear surgical facemasks in combination with either chin length plastic face shields or protective eyewear whenever there is potential for aerosol spray, splashing or spattering of the following: droplet nuclei, blood, chemical or germicidal agents or OPIM. Chemical-resistant utility gloves and appropriate, task specific PPE shall be worn when handling After each patient treatment, face shields and protective eyewear shall be cleaned, disinfected, or disposed. (5) Protective attire shall be worn for disinfection, sterilization, and housekeeping procedures involving the use of germicides or handling contaminated items. All DHCP shall wear reusable or disposable protective attire whenever there is a potential for aerosol spray, splashing or spattering of blood, OPIM, or chemicals and germicidal agents. Protective attire must be changed daily or between patients if they should become moist or visibly soiled. All PPE used during patient care shall be removed when leaving laboratories or areas of patient care activities. Reusable gowns shall be laundered in accordance with Cal/OSHA Bloodborne Pathogens Standards (Title 8, All DHCP shall comply with infection control precautions and enforce the following minimum precautions to protect patients and DHCP and to minimize the transmission of pathogens in healthcare settings as mandated by the California Infection Control Division of Occupational Safety and Health (Cal/OSHA). (1) Standard precautions shall be practiced in the care of all patients. (2) A written protocol shall be developed, maintained, and periodically updated for proper instrument processing, operatory cleanliness, and management of injuries. The protocol shall be made available to all DHCP at the dental office. (3) A copy of this regulation shall be conspicuously posted in each dental office. Infection Control Personal Protective Equipment: (4) All DHCP shall wear surgical facemasks in combination with either chin length plastic face shields or protective eyewear whenever there is potential for aerosol spray, splashing or the spattering of the following: droplet nuclei, blood, chemical or germicidal agents or OPIM. Chemical-resistant utility gloves and appropriate, task • specific PPE shall be worn when handling hazardous chemicals. • After each patient treatment, masks shall be changed and disposed. • After each patient treatment, face shields and protective eyewear shall be cleaned, disinfected, or disposed. Infection Control • (5) Protective attire shall be worn for disinfection, sterilization, and housekeeping procedures involving the use of germicides or handling contaminated items. • All DHCP shall wear reusable or disposable protective attire whenever there is a potential for aerosol spray, splashing or spattering of blood, OPIM, or chemicals and germicidal agents. • Protective attire must be changed daily or between patients if they should become moist or visibly soiled. All PPE used during patient care shall be removed when leaving laboratories or areas of patient care activities. Reusable gowns shall be laundered in accordance with Cal/OSHA Bloodborne Pathogens Standards (Title 8, Cal. Code Regs., section 5193). Personal Protective Equipment (PPE) is used to protect patients and staff from communicable diseases, but common-sense practices must also be considered when taking into account the health and safety of everyone in the dental office. One such circumstance is the presentation of a patient with a disease of airborne transmission. Such diseases would include influenza, tuberculosis, measles, chickenpox, and Infection Control If a patient presents to your office reporting flu-like symptoms, measles, chickenpox, or reports a recent diagnosis of tuberculosis, the most appropriate action is to reschedule the patient when their symptoms have resolved. Depending on their disease and condition, requiring that the patient obtain medical clearance (especially for TB), may be warranted. Hand Washing Washing your hands between patients is the most important step to avoid crosscontamination. Technically, you should wash your hands with soap and water with a vigorous scrubbing motion for 20 seconds and dry with disposable paper towels between each patient. Videos | Handwashing - CDCwww.cdc.gov › handwashing › videos https://youtu.be/d914EnpU4Fo Common Errors when Washing Hands with Soap and Water Hand Washing • Not using enough soap to cover all surfaces of the hands and wrists. • Not using friction when washing hands. • Not washing hands long enough. Should be a minimum of 20 seconds (PIDAC, 2012). • Skipping steps (e.g., fingernails, wrists, back of hands, thumbs). • Not removing all soap from hands and wrists. • Shaking water off your hands. • Not thoroughly drying your hands. • Drying your hands from wrists to fingers or in both directions. Welcome Back! Day 4 Infection Control Running the Water Lines: https://www.youtube.com/watch?v=-ec98oM00_0 Infection Control (7) All DHCP who have exudative lesions or weeping dermatitis of the hand shall refrain from all direct patient care and from handling patient care equipment until the condition resolves. Gloves: (8) Medical exam gloves shall be worn whenever there is contact with mucous membranes, blood, OPIM, and during all pre-clinical, clinical, post-clinical, and laboratory proced