Week 6 Record Keeping

Question 1

Record Keeping

Answer 1

• Is an essential component of daily practice
• Is an important oral health communication tool
• It ensures continuity of care
• Records are critical in a dental hygienist’s accountability for services.
• “If it wasn’t recorded, It wasn’t done”

Question 2

Essential Records

Answer 2

• Daily appointment record:
• Equipment service record: x-ray machines and sterilizers(a record of the date of inspection or service and by whom it was done can be crucial if a problem develops later).
• Sterilization monitoring record
• Client financial record: need to be maintained when billing occurs
• Client health record
Record of consent obtained from a client for any risky, invasive or otherwise significant service is valuable.
• WHMIS log book
• SDS record (binder)

Question 3

Record Keeping Styles

Answer 3

• Charting by exception is rare in the dental hygiene context. However, it is possible so long as there are clear written protocols that specify what is and is not meant by an entry or a lack of entry.
• Charting by reference is also quite acceptable.
E.g. Referring to a standing directive, a written assessment protocol, a recurring consent to treatment information sheet or a known treatment regime can be a handy and quick way of incorporating a lot of information in a very brief entry.

Question 4

Retention of records

Answer 4

• A clients record should be kept at least 10 years since the last entry
• The date at which the patient turned 18
• Communal screening or treatment records should be kept for a minimum of three years.

Question 5

PIPEDA

Answer 5

PIPEDA
Personal Information
Protection and Electronic
Documents Act

Question 6

Privacy Principles

Answer 6

1. Accountability
2. Identifying Purposes
3. Consent
4. Limiting Collection
5. Limiting Use, Disclosure and Retention
6. Accuracy
7. Safeguards
8. Openness
9. Individual Access
10. Challenging Compliance

Question 7

PIPEDA
Mandatory Privacy Breach Reporting

Answer 7