Week 6 Record Keeping in DH 20241 PDF

PP1 DENT 1047 Week 6 – Record Keeping – What is a dental hygienist required to record? Who provides the RDH with regulations for quality records?  CDHO Records Regulations CDHO Registrants Handbook provides specifics for the DH Standards of Practice in record keeping in C...

PP1 DENT 1047 Week 6 – Record Keeping – What is a dental hygienist required to record? Who provides the RDH with regulations for quality records?  CDHO Records Regulations CDHO Registrants Handbook provides specifics for the DH Standards of Practice in record keeping in Chapter 6 https://cdho.org/wp-content/uploads/2023/07/Re gistrantsHandbook.pdf Records regulations are mandatory Where else can a RDH find regulations for quality records?  CDHO Records Regulations Legislation piece of Dental Hygiene Act 1991 Records Part III.I 8- 12.4 Following the DH Act is NOT optional … its mandatory! https://www.ontario.ca/laws/regulation/ 940218 PHIPA & PIPEDA Personal Information Protection and Electronic Documents Act Protects personal information such as name, contact details, and financial information that is used for business purposes (example, method of payment for dental services). Dentistry is a commercial business as well as healthcare. PIPEDA ensures transparency, accountability, and the rights of individuals to access and correct their personal data. Personal Health Information Protection Act Protects personal health information, which includes medical and dental records, treatment plans, dental histories, and other sensitive health data. PHIPA emphasizes confidentiality, patient consent, and the secure handling of health records. Quality Record Keeping in DH Practice CDHO emphasizes that maintaining quality dental hygiene records is essential for ensuring continuity of care, legal compliance, and client safety. Accurate records support effective communication among healthcare professionals, document the care provided, and help identify trends in patient health. These records also ensure that the hygienist is meeting professional standards and upholding ethical obligations in practice. Proper documentation contributes to optimal client outcomes and aligns with the regulatory and quality assurance requirements of the CDHO​ Tying into last weeks ‘ethics’ learnings … How does ethics fit into record keeping? Tying Ethics to Record Keeping Ethics, professionalism, and client advocacy are foundational to quality record-keeping in dental hygiene because they ensure that every entry made is a truthful reflection of care provided, thereby fostering trust and transparency. Accurate and complete documentation not only upholds professional standards but also serves as a tool for advocating for the client’s best interests, ensuring their informed consent and promoting patient safety. By maintaining honest and precise records, DH demonstrate their commitment to integrity and ethical practice, reinforcing the truth in their interactions and safeguarding both the client and the DH​.  What about DH record keeping from a legislative lens? From a Legal Perspective From a legislative standpoint, quality record-keeping is integral to mitigating legal risks and protecting both the DH and client. Complete and accurate documentation serves as a primary defense in legal proceedings by demonstrating adherence to professional standards, compliance with regulations, and transparency in client care. Inadequate or incomplete records are frequently cited as contributing factors in legal disputes, as they may indicate negligence or a breach of duty, thereby undermining the dental professional’s position. Maintaining high-quality records aligns with CDHO standards and helps ensure that all actions taken are legally and ethically defensible. Client Records Legal Highlight ECORD NO R = RD IT DID NOT NO RE CO HAPPEN = D EF EN SE NO  Document the truth and only the truth Be transparent, accurate and detailed Do not leave room for interpretation Advocate and protect the client and YOU! Are there client record keeping principles? Client Record Keeping Principles Legible Type legibly, accurately and concisely Original Date Date all entries and record entries chronologically and immediately. Addendum Date Refrain from adding information to an entry at a later time. Record missed information as a “late entry” which is dated using the date of the late entry verses initial entry. Many dental client management software (CMS) programs have an option for an addendum entry. Client Record Keeping Principles Signature Digitally sign all entries. Signed by the person who performed the procedure. Locking Chart CMS typically have a default that once clinical digital note is signed the record is locked and cannot be altered. As a RDH why do you want to ‘lock’ your client clinical record to prevent edits and/or alterations? Why or why not? Client Record Keeping Principles Objective Writing Do not make subjective comments on the client record – comment which reflect on the personality or idiosyncratic behavior of a client which are judgmental in nature do not belong on the record Example: “client was in a bad mood and questioned everything” … instead … “client inquired about the following” Or … “client was very apprehensive and asked many questions” Client Record Keeping Principles Terminology Use proper dental terminology, this is a professional record. Abbreviations All abbreviations require a legend, and all staff must follow the same abbreviations. In a compliance review the abbreviation list must be provided to the CDHO assessor. Continuum Entries for a given date should be continuous, with no unusual or irregular blank spaces. Administration All appointment activities must be recorded. This includes the when a client has missed, cancelled and moved an appointment. It also includes when the client was confirmed.  It’s a busy day at your new RDH job at Smiles R Us pediatric office. You notice you had a cancellation and are about to enter in the client note that the appointment was cancelled. The appointment has already been removed from the CMS appointment book. What should you do? Is it YOUR job? Why or why  Should you include the specifics if a client becomes abusive with language and actions? Are there still offices using paper format for client record keeping? What are the principles for paper? Manual Paper Entries Write legibly, accurately and concisely Record using non-erasable ink and do not change pens in mid entry Sign all entries – entries should be signed by the person who performed the procedure Do not use a correction aid. Example: liquid paper Errors are crossed out with one single line with initials placed beside the correction and the correction date  Quick Case Study Congratulations on your week off from your DH job… well deserved! As you arrive back to work on Monday and start doing chart audits you notice during the week you were away the temporary RDH replacing you created client clinical chart entries under your name. What should you do? Is there a tool we discussed last class that would help you in this ethical dilemma? Is it an ethical dilemma? Why or why not? What is the purpose of client records? Purpose Of Client Records Legal document serving as representation of the dental client providing an accurate client specific information Provide a baseline and eventually a history of the care and treatment of the client Provide a creditable defense for the dental hygienist in a case of a malpractice suit What are the components of a dental client record? Components of Client Records General Client Information Include the correct name, address, and date of birth. Document physician, dentist, emergency contact names along with their addresses /ph # Medical History Medical history must be updated at each dental hygiene appointment. Determine if a Client-Specific Order (CSO) is required. Dental History Document the client’s current concerns or complaints related to dental health. Components of Client Records Dental and Periodontal Charts Must include comprehensive records of the client’s oral health status and diagnostic data. Treatment Records Document all findings from examinations, including assessments, identified needs, and detailed treatment plans. (ADPIE  ADP) Procedures Performed Specify who provided the treatment, what was done, and the date. Clearly state the nature of the care, rationale, and where in mouth service provided (example scaled mandibular teeth 47 to 35) Components of Client Records Treatment Notations Include details about the clinical conditions presented, such as gingival health, oral hygiene status, and specific areas of change. Use precise language and avoid vague descriptions like "some deep pockets in the posterior" as they lack definitive information... Instead 7 mm pocket di of the 26. Adverse Occurrences Document any adverse events that occur during or following treatment, such as hematomas, tissue tags or excessive bleeding. Ensure that the client has been informed of these occurrences and record the communication accurately. Components of Client Records Postoperative Instructions Include specific recommendations for post-treatment care to ensure client understanding and compliance. Medication Details Document any medications given or taken as a condition of treatment, including dosage and timing. Client Education Record any educational discussions conducted, ensuring that the information shared is relevant to the client’s needs. Components of Client Records Time Allocation Specify the amount of time spent providing dental hygiene services for accurate record-keeping (debridement (sc/rtpl), selective polish, oral hygiene instruction, desensitizing). Follow-Up Care Indicate what treatment is needed next and the recommended timeline for subsequent visits. Client Response Note how the client responded to the treatment provided, including any adverse reactions or improvements observed. Components of Client Records Authorization and Controlled Acts Document client-specific order for scaling and root planing if there is a CSO. Record all controlled acts that were performed in accordance with the order. Treatment Recommendations Provide a detailed record of the treatment options discussed and selected by the client. Client Consent Clearly indicate that informed consent was obtained or declined for the recommended care. Components of Client Records Referrals and Follow-Up Note any referrals made to other healthcare professionals, including the reason and outcome. Keep track of outgoing and in coming referral reports. Incomplete Treatments & Refusals Record any procedures that were started but not completed, with an explanation for discontinuation. State any refused procedures and objective discussions with client. Components of Client Records Correspondence and Consent Records Include all correspondence notes, signed consent forms for the release of information, and records of telephone conversations involving or concerning the client. Treatment and Scheduling Details Maintain a detailed record of treatment dates and any scheduling changes, including cancellations and late arrivals. Release of Information Record the date and recipient of any released records, ensuring that written client authorization is properly documented and enclosed.  Are there non-written records that are still part of the clinical client chart? Non-Written Client Records Radiographs Photographs 3D Imaging Regular: instead of impressions 3D Imaging Comprehensive: Cone Beam Computed Tomography (CBCT) scan Models: working or study Cephalometric tracings Other Required Records Procedure Manuals and Administrative Tasks Maintain detailed procedure manuals for operations Document appointment schedules, order inventories, equipment repairs, and service records. Ensure all documentation complies with relevant legal standards and organizational protocols. Appointment Book & Financial Record-Keeping Keep a daily appointment record of all client visits. Financial records must include treatment procedures performed, fees charged, payments received, and issuance of receipts. Other Required Records Legal Compliance , Quality Assurance & Equipment Maintenance Ensure adherence to the HARP (Healing Arts Radiation Protection) quality assurance program by maintaining accurate compliance records. N95 respiratory fit test record, CPR certificates, proof of malpractice insurance, etc. Maintain equipment service records. Infection prevention and control program records, particularly for sterilization logs, as part of routine quality assurance. Include detailed records of any corrective actions or equipment maintenance undertaken. Staff training records.  Quick Case Study You have now been working as a RDH for 6 months at Big Smiles Studio. You have a cancellation and decide to screen the sterilization monitoring quality assurance logs and you notice on several occasions there are blank lines with missing entries. What should you do? Is this type of log sheet a legal document? You did not do the sterilization the CDA did? Is this YOUR problem? Why or why not? Impact of Omissions on Defensive Record-Keeping Legal and Compliance Risks Missing information can indicate negligence, leading to potential legal liabilities. Undermines Accountability Incomplete records weaken professional credibility and adherence to standards. Client Safety Concerns Omissions can disrupt continuity of care and compromise patient safety. Evidentiary Challenges Incomplete documentation makes it difficult to defend actions in legal or audit scenarios. Retention of Client Records: Legal and Professional Obligations Minimum Retention Period Client records, including health and financial documentation, must be retained for a minimum of 10 years following the client’s last visit or last point of contact (which ever is last). Retention for Minor Clients For clients under the age of 18, records must be kept for 10 years after the client turns 18. Implications of Record Destruction Destroying or improperly managing records can severely hinder the ability to defend against legal actions, rendering the healthcare provider virtually indefensible in disputes. What about service records and sterilization logs? How long are they retained? Retention Of ‘Other’ Records Daily appointment record +Equipment service records +IPAC QA logs +Radiation safety QA logs =10 years for all ! Fanshawe College Oral Health Clinic follows CDHO’s Records Regulations from Dental Hygiene Act 1991: “12.4 (1) Subject to subsection (2), every financial and client health record shall be retained for at least 10 years following, (a) the last intervention with the client or the date of the last entry in the client health record, whichever is longer; or (b) the day the client became or would have become 18 years old, if the client was younger than 18 at the time of the last intervention with him or her. O. Reg. 9/08, s.” www.cdho.org Quick Case Study You have a cancellation and decide to help the administrative team with answering phone calls and calling overdue clients. You place a call to Mrs. Jane Doe to schedule her continuous care appointment and you note her last appointment was on August 21, 2010. Today is August 10, 2011. You discuss the importance of regular continuous care appointments and Mrs. Jane Doe informs you she is not ready for an appointment, and she will call you when she is. How long does Pearls Dental need to keep her records? a. Until August 22, 2020 b. Until August 11, 2021 c. Until August 21, 2020 Guidelines for the Release of Client Records Client records may be released to the following individuals upon a formal written request by the client: The client themselves. Health care professionals identified by the client. A designated personal representative authorized in writing by the client. The legal representative of a deceased client. Authorized guardians for clients who are incapable of acting independently. Best Practices for Releasing Client Records Client Authorization Records should not be released without obtaining prior written consent from the client, ensuring compliance with privacy regulations. Retention of Original Records Only copies should be provided, including any radiographic images. The original records must be retained to ensure data integrity and continuity of care. Confidentiality Client information and records must be treated as strictly confidential at all times. Protecting confidentiality is a core professional obligation and fundamental to maintaining trust. Breaches of confidentiality are considered serious violations of professional conduct and may result in disciplinary action. Who owns the client’s records? Decisions of The Supreme Court of Canada Client records are the property of the owner of a practice or clinic A DDS and RDH can own a clinic Client is entitled to, upon request examine and copy all information in his/her/they medical/dental file, including records prepared by other doctors Destruction Of Client Records Destruction of client records must be done, such that the confidentiality of the client is maintained - ie. Cross-shredded or hard drive destroyed If paper: mark destroy date on the outside of inactive client records Digital Records Information must be available and must be secure from loss, tampering, interference or unauthorized use of access Computerized records and intraoral cameras have the potential of allowing video access CMS and any computer applications must be password protected Computer systems must have firewall and malware protection CMS must be kept in optimal performance …  Where does process of care (ADPIED) fit into record keeping?  Process of Care ADPIED becomes the framework to both the delivery of ‘actions’ of DH services AND Documentation of all the steps performed in those actions ADPIE(D) … do it … then write it!!! Does the element of some of our team members being in an occupation verses being a professional have a bearing on the topic of record keeping?  If its not written it didn’t happen! Its YOUR registration at risk if short cuts are taken. Protect YOUR SELF! Advocate for the Client! Your recordkeeping is a reflection of your practice! Your practice is a reflection of YOU!  Wednesday class… Professional Boundaries Reminder Quiz 1 extended to Oct. 11 @11:59 Continue with Discussion Posts if its your groups due date Returning from fall break will be midterm exam in Week 8 … good news … content is from Week 1-6 … does NOT include Week This Photo by Unknown Author is licensed under CC BY 7!!!!!!