Test 2 Flashcards
Client goals should be:
Client-centered
Specific, clear, concise
Measureable & observable
Time-limited
Realistic
Goals should include:
Subject
Verb
Criterion
What are the 8 human need deficits?
- Protection from health risks
- Freedom from fear and stress
- Freedom from pain
- Wholesome facial image
- Skin and mucous membrane integrity of head and neck
- Bioloigcally sound and functional dentition
- Conceptualization and problem solving
- Responsibility for oral health
What is the “related to” portion of the dental hygiene diagnosis?
Etiology (cause)
What is the “evidenced by” portion of the dental hygiene diagnosis?
Supporting facts of diagnosis
True or False: goals need to be numbered
True
What records does a dental hygiene need to keep in regards to the Dental Hygiene Act 1991 - Records Regulation?
Clinical notes of treatment
Equipment service record
Equipment sterilization record
Financial record for each client
Health record
What does the client’s health record need to contain?
Name
Address
Date of birth
Date of each professional contact
Amount of time for each intervention
Name and address of primary care provider
Name and address of client’s primary care dentist
Name and address of any referring health professional
Appropriate medical and dental history
Every written report received by the member respecting examinations, tests, consultations or treatments performed by any other person
Copy of every written communication
Each examination, clinical finding and assessment relating to the client
Medication list
Any dental hygiene treatment plan
Each treatment or procedure performed
Any advice given by the member
Every controlled act including the source of authority to perform the controlled act
Every referral of the client by the hygienist
Every procedure that was commenced by not completed
A copy of every written consent
Every refusal of a treatment
What needs to be included in the ROC for cornoal polishing?
Name of the product
Grit
Flavour
Location
Time spent in minutes
What needs to be included in the ROC for Fluoride?
Chemical name
Percentage of fluoride
Flavour
Application technique
POI
What is needed in the ROC for desensitizing?
Reason for use
Location
Product name
Percentage
Time spent
POI
Client satisifcation where previously done
What is needed in ROC for pit and fissure sealants?
Location
Materials
Occlusion
Adjusted if needed
Instructor who checked
What is needed in ROC for alginate impressions?
Tray size
What was taken
How many were taken
Material used
Client reaction to procedure
What information is needed in ROC for topical anaesthetic?
Reason for use
Product used
Percentage of active ingrediant
Specific location applied
Flavour if applicable
What is needed in the ROC for local anaesthetic?
Reason for use
Percentage of active ingredient
Name of product
Ratio of epinephrine or none
Injection location
Number of carpules
Client reaction
The name of DDS providing injection
What does Adj mean?
Adjust (ed) (ment)
What does BW mean?
Bitewing x-rays
What does Ct mean?
Client
What does CR mean?
Composite resin
What does EO mean?
Extra-oral
What does Fl mean?
Fluoride
What does APF mean?
Acidulated phosphate fluoride
Wbat does NaF mean?
Sodium fluroide
What does FMS mean?
Full Mouth Series (x-rays)
What does IO mean?
Intra-oral
What does Imp mean?
Impressions
What does Md mean?
Mandibular
What does Max mean?
Maxillary
What does PR mean?
Plaque record
What does MH mean?
Medical history
What does NC mean?
No change
What does OHI mean?
Oral hygiene instruction
What does PFS mean?
Pit and fissure sealant
What does PA mean?
Periapical (x-ray)
What does POI mean?
Post operative instruction
What does Sc mean?
Scale(d)
What does Var mean?
Cavity varnish
Wht does Min mean?
Minutes
What does Sup by mean?
Supervised by
What does ICO mean?
Informed consent obtained
What is the dental hygiene evaluation for?
To determine whether the client’s goals have been attained
To determine if the care outcomes have been attained
To verify that the client has received the planned services
True or False: evaluation includes measuring the client’s level of satisifaction
True
True or False: evaluation does not allow the dental hygeinist to modify the dental hygiene intervention plan
False. The evaluation allows the dental hygienist to modify dental hygiene intervention plans and programs based on outcome measures, changing needs, and new information
To determine the future needs, and further care for the client interval for on-going preventative care or any consultation or referal to another health professional the hygeinist must complete
Evaluation
When must the dental hygienist communicate and collaborate with the client about goals, outcomes, and/or interventions performed or to be performed?
At every appointment
The evaluation framework is a plan within a plan or program that measures:
The outcomes using a set of key indicators that have been established based on the initial assessment and the client’s identified needs.
What is the failure to evaluate an indication of?
The unwillingness to assume responsiblity for quality of care provided.
What are the three levels of goal attainment?
- Goal met
- Goal partially met
- Goal not met
What are the types of evaluation used in dental hygiene?
Process evaluation
Outcomes evaluation
Structural evaluation
Can goals be met at various appointments?
Yes
If the goals are met at various appointments what needs to be recorded when the goal is met?
The date and how it was met
What are the three components requires when writing/recording an evaluation?
Decision of the dental hygienist
Supporting evidence
The date on which the evaluation took place
What future needs/care are determined by the evaluation results?
Future needs priorities
The necessity of further care
Consultation/referral to another health care provider
The client re-care interval
What is the client satisfaction survey?
A Durham College Dental Clinic Feedback survey that is provided to the client in a link at the end of care.
What does the client satisfaction feedback help the hygiene student understand?
That you met your client’s chief concerns
If the service you provided met teir expectation related to their comfort level
The success of your communications
What happens to clients who are not maintained in a supervised recall program?
They show obvious signs of recurrent periodontitis
Should motivational techniques and reinforcement of the importance of the maintenance phase of treatment be considered before performing periodontal treatment?
Yes
What are the considerations when establishing recare intervals?
Caries
Unresolved inflammation
Periodontal condition
Medically compromised
Family history
Ortho concerns
What will happen if you don’t indicate the continous care interval in the Dentrix Family File?
You will lose marks on your chart audit
What factors indicate a 4-6 week re-eval is needed?
Systemic factors
Risk factors
Agressive forms of the disease
Pockets of 6mm or greater
Advanced bone loss or attachment loss - furcations, mobilities
Adherence on the part of the client requires the discussion of the need for the re-evaluation visit as an essential part of the NSPT care plan at the time of case presentation and informed consent
In semesters 4, 5 and 6, what DD levels may be asked to return for 4-6 week re-eval?
DD3
DD4
What does a 4-6 re-eval include?
MH update
EO/IO update
Discussion with client regarding how they are doing with previously taught education and determine/document if changes are required
Soft and hard deposit assessment Assessment of the soft issues
Full mouth probing
CAL
Bleeding Index
Plaque Record
Full debridement/deplaquing
All findings are to be compared to previous findings and recorded in ROC
What happens if during the re-eval there are extensive deposits that have reaccumulated?
The client must be reappointed for a continuous care appointment
Are additional credits awarded for re-evaluations?
No
What may be prescribed at the reevaluation?
Chlorhexidine rinse
Who determines if Chlorhexidine rinse needs to be prescribed?
The student in conjunction with the RDH instructors and the DDS who will prescribe and dispense the chlorhexidine
What needs to be recorded in the ROC for the re-eval?
Addressing improvement in gingival health - yes or no?
Comparison of pocket depths - reduction? Indicate areas
Assess clinical attachment level - indicate areas
Any removal of calculus - where? time spent?
Client treatment goals - were any evaluated?
Review OHI and client compliance
When can the appropriate recare interval be determined for a client that requires a re-eval?
Upon completion of the re-eval
What are the reasons for referral?
Caries
Perio
Night guard
Ortho
Oral surgeon
Periodontist
What forms need to be completed for a referral?
A paper copy to give to the client signed by RDH or DDS
An electronic copy in Dentrix signed by RDH or DDS
What needs to be documented in the ROC for a referral?
Client has been informed of the nature of the referral
The benefits of following up as well as risks ad possible side effects of not following up with referral have been explained and documented
Indicate hard copy given to client and electronic copy completed
What is the rationale for a chart audit process?
Quality control
Understanding areas of record keeping that may have not been met
Legal guidelines
Why is quality control a rationale for the chart audit process?
Shows Standards are being met
Why are legal guidelines a rationale for the chart audit process?
Allows the office to ensure all are their part
What do you do if you find an ROC is missing information during your audit?
Add an addendum
Who needs to correct the information if an instructor indicates changes need to be made from the audit?
The student
Where does the student put their name to show they were the provider in the client’s Family File in Dentrix?
In the driver’s lisence spot
What needs to be put under Prov 2 on the client’s file?
DH3A (DH + semester + group)
What happens when a client in the middle of care fails to attend a scheduled appointment with or without notice?
Determine the reason and provide another opportunity.
What needs to be recorded in the client’s ROC if a client fails to attend an appointment with or without notice?
Record information regarding why the client missed the appointment and document the conversation you had with the client.
What happens when a client missed more than one appointment and the reasons are not substaintial?
You may defer their treatment to a time when it is convenient for you, or you may need to advie them you no longer have appointments available for them, if the case warrents this decision.
When a client misses more than one appointment, and the reasons are not substantial, and you are unsure how to proceed, what do you do?
Discuss options with your advisor, and/or the recepionist. Every phone conversation must be recorded in the clinical notes.
What needs to be done to the client file is they indicate they are not returning?
The client needs to be inactivated
What needs to be added to the Post Care Evaluation form if a client does not complete care?
Identify any goals complete or incomplete and future needs, and signed off by an instructor.
What happens if care is incomplete and you are on break the following semseter?
Care needs to be transferred to another student (speak to receptionist/advisor)
What is the expectation of the RDH/DH Student with respect to the Client who smokes tobacco?
Education about health risks, connection between tobacco use and oral cancer, periodontal disease
Motivate clients to quit
Provide cessation options
Refer
What is tobacco cessation?
Quitting or stopping the use of tobacco
True or False: Most tobacco users require mutliple attempts at stopping their tobacco use before they are ultimately sucessful.
True
How many smokers will return to smoking within a year?
85%
People who relapse after 6 weeks of not smoking usally don’t do it because of nicotine withdrawl. Why do they do it?
They find themselves in situations that make them want a cigarette.
A UofT study found people quitting smoking requires up to ____ attempts.
30
What happens to the brain from chronic exposure to nicotine?
With chonric exposure to nicotine, brain cells adapt to compensate for the actions of nicotine.
What is the process of brain cells adpating to compensate for the actions of nicotine with chonric exposure to nicotine called?
Neuroadaptation
True or False: Over time, less nicotine is required to achieve the rewarding effects.
False. Over time, more niotine is required to achieve the rewarding effects.