Speaker: Erin Kierce, RDH, MS, MPH
Program Track: Clinical Practice
Course Description: The proper documentation of patient care, information, and treatment is vital for quality care delivery as well as a fundamental component within the field of dentistry. The dental record is a legal document that records any and all patient encounters, including disease diagnoses, clinical notes and observations, treatment and services performed, and all patient-related communications, including informed consent, oral hygiene recommendations, and review of medical history. The dental professional must be consistent and accurate with the recording of patient information as well as ensure the confidentiality of the information.This course will provide a comprehensive review of proper chart documentation as it relates to dentistry. The speaker will also describe the process and importance of establishing QA and QI systems within your practice, including clinical protocols and internal auditing, and how chart documentation can be improved, monitored, and maintained within an office. This course will also describe how accurate record keeping can be used in defense of allegations of malpractice and BORID investigations.
- Define and distinguish all essential components of the dental record.
- Characterize and identify the scope of practice for dentists and all auxiliary staff as it relates to chart documentation maintenance.
- Appreciate the benefits and significance of establishing medical necessity, including documentation of disease diagnosis and plan of treatment.
- Understand the legal aspects of standard of care, informed consent, vicarious liability, and professional negligence as it directly relates to QA and risk management measures.
- Recognize the role of proper documentation in quality patient care delivery, as well as identify methods to monitor and improve the documentation processes within an office.
CE Credit Hours: 2.0
Original Date of Session: 21 June 2019
The American Dental Hygienists' Association is designated as an approved provider by the American Academy of Dental Hygiene, Inc. #AADHADH (Jan. 1, 2021–Dec. 31, 2021). Approval does not imply acceptance by a state or provincial Board of Dentistry. Licensee should maintain this document in the event of an audit.
The American Dental Hygienists’ Association is an approved provider of dental continuing education as recognized by the Dental Board of California, Provider #5238.