Unit 6 Flashcards
Describe informed refusal
Give client all necessary information to make an informed decision
Analyze client’s refusal to determine how/why they came to this decision
Client will sign they are refusing care
Describe ongoing montioring
Process of continual review and reinforcement of client’s progress towards achieving goals
DH and client have active roles
Evaluation of client progress is ongoing
CDHO Records Regulation state each client record must include
Date of each professional contact with client/decision maker and method of contact (phone, in person, electronically)
Amount of time clinician/member spent providing care for each intervention
Every written report received by the clinician/member repsecting examinations, tests, consults, or tx performed by another for the client
Notation for each exam, clinical finding and asssesment for the client
Any medication taken by the client as a precondition to tx or exam by the clinician/member for each intervention (name of med, time taken, who prescribed it, who administered meds)
Any dental hygiene care plan/treatment plan
Each tx or procedure performed for each intervention and identify if the person performing the tx if not the clinician/member
Any advice given by the clinician/member including any pre-tx or post-tx instructions given to client
Every controlled act performed by the clinician/member and the source of authority to perform the controlled act
Every referral of the client by the clinican/member to any other person
Every procedure that was commenced but not completed with the reason why
Copy of every written consent provided by the client
Every refusal of tx or procedure by the client
Every part of the record must be able to be idntified as belonging to a specific client by the use of
A name, number, or code
The date of treatment/care provided must be on
All records including radiographs
Entries must follow a logical
sequence of care order
When do you write the record?
As you perform each step of care
Do entries need to contain client’s symptoms, tolerance and responses to services with procedures noted verbatim?
Yes
Do entries need to contain adverse occurrances that took place during or after treatment?
Yes
Can you use subjective comments in the record entries like personality information?
No
Can you leave any blank spaces in the record of care performed?
No
How can you use abbreviations in your record of care?
Common dental abbreviations WITH a master list posted
What is included in a clinical record of care note?
- Date + Time
- COVID Screening
- MH Completed + Vitals
- DH + Nutritional Assessment Completed
- PPR with Listerine
- Authorization to controlled performed acts
- Risks, benefits, side effects of care discussed, ICO
- EO/IO
- Completed plaque record with Trace disclosing solutation. PR ___%
- Tx.
- POI given
- Client tolerate procedure ___________
- Date + Time
