Chapter 10: Documentation for Dental Hygiene Care PDF

Chapter 10 Documentation for Dental Hygiene Care  Learning Objectives Define key terms and concepts related to dental records and charting Describe concepts related to confidentiality and privacy of patient information Discuss components of patient’s permanent, compreh...

Chapter 10 Documentation for Dental Hygiene Care  Learning Objectives Define key terms and concepts related to dental records and charting Describe concepts related to confidentiality and privacy of patient information Discuss components of patient’s permanent, comprehensive dental record Explain systematic method for documenting patient visits  Introduction to Documentation Complete records for every aspect of care Records can be in multiple formats LEGAL DOCUMENT Chronological Systematic Comprehensive Accurate Unaltered Signed by the dental hygienist Copyright © 2017 Wolters Kluwer All Rights Reserved 3 Follow the PROCESS OF CARE All Assessments The Diagnose You and the Patient’s Plan Moving Forward Implementation Evaluation Copyright © 2017 Wolters Kluwer All Rights Reserved 4 Ethical Documentation Copyright © 2017 Wolters Kluwer All Rights Reserved 5  The Health Insurance Portability and Accountability Act Health Insurance Portability and Accountability Act (HIPAA) of 1996 Took effect for dental practices in the United States on April 14, 2003 Protects patient records and other health- related information  The Health Insurance Portability and Accountability Act Federal law; however some states have stricter laws that take priority over federal standards Law applies to:  Healthcare facilities  Healthcare insurance companies  Healthcare providers Two separate components addressing PRIVACY and SECURITY Copyright © 2017 Wolters Kluwer All Rights Reserved 7  The HIPAA Privacy Rule Protects individuals medical records and health information Protection of privacy and who can access Includes rights of the patient Responsibilities of healthcare facilities Responsibilities of healthcare providers  The HIPAA Privacy Rule Patients have the right to: Receive a copy of personal health records. Ask to change incorrect or incomplete information. Receive reports on when, why, and with whom their health information is shared. Decide, in some cases (such as marketing), whether health information can be shared. Ask to be contacted regarding health information in a specific location or by a specific method such as telephone or mail. File a complaint with the provider, health insurer, or the U.S. government regarding concerns about use of their health information.  The HIPAA Privacy Rule Healthcare facilities are responsible to: Develop required privacy and confidentiality forms. Adopt written privacy policies and educate staff about confidentiality of patient information. Appoint staff privacy officers and privacy contact persons. Provide patients with a Notice of Privacy Practices document at the beginning of their care and receive signed acknowledgment of receipt. Implement security measures, policies, and formal protocols that protect patient information. Conduct analysis of security risks and vulnerabilities. Establish sanctions for workforce members who fail to comply with policies.  The HIPAA Privacy Rule Healthcare providers are responsible to: Comply with protocols and practices that protect patient information and avoid inappropriate disclosure. THAT MEANS YOU!!!!  The HIPAA Security Rule Updated in 2013; includes standards set to strengthen digital security and enhanced enforcement for protection of health information that is held or transferred in electronic form Three separate standards include:  Administrative safeguards  Physical safeguards  Technical safeguards  The HIPAA Security Rule Administrative safeguards -limitation of access to appropriate members in the workforce Physical safeguards -use of storage systems and procedures that prevent access for unauthorized individuals Technical safeguards -use of technology, such as coding and encryption, to control access to patient information  The Patient Record Purposes and Characteristics: Accurate record keeping is essential to a safe, thorough, and caring dental hygiene practice as well as clinical and ethical risk management The Handwritten Record: Historically, dental healthcare maintained handwritten documentation of patient records The Electronic Record: faster, more convenient, and better organized mode of information gathering, preserving, and sharing patient information with other healthcare providers  Components of a Patient Record REQUIRED COMPONENTS: Medical history and vital signs Dental history Clinical assessment and diagnosis Treatment recommendations and written treatment plan Progress notes for each patient visit Signed acknowledgment of confidentiality measures (HIPAA) Copyright © 2017 Wolters Kluwer All Rights Reserved 15  Components of a Patient Record Additional components, required when applicable, include: Informed consent forms Radiographs and radiographic assessment Periodontal risk assessment Caries risk assessment Oral cancer risk assessment Trauma and/or surgery anesthesia records Study models Oral photographs Orthodontic records, if available Laboratory orders and test results Referral records and copies of consultation correspondence with dental specialists or medical practitioners Copyright © 2017 Wolters Kluwer All Rights Reserved 16  Documented Clinical Assessments Extra and Intra Oral Exam Deviations from normal Hard and Soft Tissues Exams Dental Chart Radiographs Study Models Periodontal Exam  Care Plan Records Dental hygiene care plan: Includes dental hygiene diagnostic statements Addresses the patient’s risk factors Is included in the patient’s record  Informed Consent Documentation of informed consent must be obtained before initiating treatment  Documentation of Patient Visits Purpose: Documentation completed during or immediately following a patient visit, sometimes referred to as a progress note, is a chronologic history of treatment received by the patient during each appointment Essentials of Good Progress Notes: ALL aspects of the dental hygiene process of care and record all interactions between the patient and the practice Systematic Documentation: assures that no details are missing Risk Reduction and Legal Considerations:excellent compréhensive documentation in each patient record entry is the best protection for the clinician against allegations of wrongdoing.  QUESTIONS? 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