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Record Keeping

Dental Hygiene Billing

CCP Guidelines

SDHA related Q & A

Getting to the

Root of the

Matter

SDHA Related Q & A • Opportunity to ask questions about SDHA

legislation, guidelines, programs, etc.

Record Keeping • Importance of adequate chart documentation

• Review standards relating to chart documentation

• Components of a dental hygiene record

• Examples/Samples

Dental Hygiene Billing • Review standards relating to dental hygiene billing

• Dental Hygiene Billing Communication

• Appointment Examples

CCP Guidelines • Review CCP Guidelines

• Changes to PL Tools

Record Keeping

• Importance of adequate chart documentation

• Review standards relating to chart documentation

• Components of a dental hygiene record

• Examples/Samples

Importance of Chart Documentation

• Legal document to accurately and adequately depict a

client’s general and oral health, concerns, and services

provided

• Assists dental hygienists in their day-to-day practice.

• Accurate chronological records help practitioners provide

comprehensive care and ensure continuity and consistency

between practitioners

• Rising trends in complaints and inquiries from insurance

providers

• Financial implications

• Forensic odontology

Accurate dental records

protect both the client and

the oral health care provider

Good recordkeeping will also be useful to the other

members of the oral health care team:

• Dentists (and not necessarily the current dentist if the

client changes offices),

• Other dental hygienists

• Dental assistants and support staff (e.g., for scheduling

or billing purposes).

Continuity of Care

Clients are entitled at any time to a report of your assessment, treatment

and prognosis.

• Clients may request them for use by others, such as insurers, employers

and lawyers.

• Clients may need the information for legal proceedings, such as a

disability claim, a motor vehicle accident benefit, a custody battle, or a

discrimination suit on the basis of disability.

Preparing Reports

Failure to provide an adequate report because

of poor records may not only embarrass you

but will also increase the likelihood of your

being asked to testify in court as a witness.

Clients, employers, payers and the SDHA will rely heavily on your record in

assessing the adequacy of your conduct or competence. Accountability is

not restricted to disputes with clients.

The quality of your records is generally seen as a good measure of the

quality of your practice.

Dental Hygienists Accountability & Professional Responsibility

The SDHA is seeing an increasing amount of complaints

and getting inquiries by insurance providers

An adequate and accurate client

record is the first line of defense with

inquiries and complaints

If it wasn’t recorded,

it wasn’t done

Common Documentation Errors

Failure to complete and/or document:

• Medical history

• Dental hygiene diagnosis

• Dental hygiene treatment plan

• Informed consent or refusal

• Entries with adequate details

• Provider initials after entries

Why?

• Tedious

• Takes time away from client contact

• Postponed until the last minute or is completed at the end of

the day

• Electronic records

• Dental practice routines/protocols

A dental health record…

Is the comprehensive, ongoing file of assessment findings, treatment

services rendered, dental outcomes, notations and contacts with a client.

Simply…it should give a clear idea of what happened

during a visit and why

A dental health record should include…

Date

Personal data on the client that must be updated routinely Contact information, insurance providers, physician

A health history, including medication, habits and health conditions

A dental history, including information on previous treatments and

the client’s response to those treatments

Care & Treatment, (according to the ADPIE process of care) including

a careful recording of: Assessments

Dental Hygiene Diagnosis

Treatment plan

Treatments rendered, including post-op care

Evaluation

Informed Consent/Refusal

Notes from contact with the client

Referrals/Consultations

Results/letters from specialists

Initials of provider

Time spent performing procedures

Comments about the client/appointment:

• Can be recorded in the dental record, but should relate to the care

of the patient

• Be stated in objective, professional, non-judgmental terms

Example:

If you suspect that a client of being under the influence of excessive

alcohol consumption, describe this in the record according to the

conditions observed:

• Heavy odor of alcohol

• Slurred speech

• Unsteadiness requiring my assistance

“Client was drunk”

Comments about the client:

Notes about the client’s personal life (job, family, holidays, etc) can be

made in the record, but on a sticky note is best.

Errors in an entry:

• Make the correction in a timely manner

• A single line (strike-through) should be drawn through the entry, followed by a note that an error was made. The initial text should be able to be seen (no white out or scribbling over)

• The correct information should then be recorded and the entry signed and dated

• If a correction is distanced from the error by intermediate entries, a notation should be made regarding the location or the error and its correction.

• Do it yourself! Do not delegate to another staff member

• If it is in an electronic record, the above principles should still apply:

• Ensure original entry still exists

• Initial or electronic signature

Record Keeping Tips:

• Consistent for all clients

• Develop a system everyone is comfortable with or guidelines for your dental practice

• Templates make life easier (pre-printed chart, or e-templates)

• Tick boxes/options (CHX pre-rinse )

• Review the records regularly, especially medical and dental history being updated to reflect current conditions/issues/trends

• Entries should be clear, concise, legible and permanent (INK)

• Initials or provider logins are a must!

• Acronyms or jargon should be avoided as much as possible unless a clear glossary of terms is used within the dental practice

Electronic Records

• Permanent entries

• Corrections added as a late entry

• Initials (not just selecting your provider number/code)

• Individual staff logins

Informed Consent/Refusal

• Obtaining informed consent is a process

• Rests on the principle that clients should make their own treatment decisions

• The role of the dental hygienist is to provide information (risks, benefits, costs) and make recommendations that will enable clients to make informed choices

Rationale for Informed Consent/Refusal

• Individuals have control of their bodies. We should not touch, examine, or otherwise interfere with another person’s body without true consent. Meaningful consent requires that the client knows all the information needed to make an informed choice

• Quality service for a dental hygienist includes advising them of their options and partnering with them. The “best possible service” means that the individual client’s goals, expectations, needs and abilities direct the selection of all preventive and therapeutic interventions

• Dental hygienists have a fiduciary duty of good faith and loyalty to their clients. We have specialised knowledge and expertise that the clients do not. Clients are vulnerable and it is our responsibility to act only in the client’s best interest

3u scaling, prophy, fluoride on every

client is not meeting our fiduciary duty

Why is Informed Consent Is Not Always Obtained

• We assume a level of understanding that does not always exist

• We live day in and day out with oral health matters, but clients do not

• We are in a rush

• Tremendous pressure to “get through” your client visits

• Poor communication skills

• Making a statement of need is not communication. We have to allow for feedback and understanding

• Ignorance of the requirements for informed consent

• Does not just apply to invasive procedures. Should be FOR ALL treatment decisions.

Elements of Informed Consent

• Informal – medical history

• Who will be providing treatment • Your name, what profession you belong to, if another provider is scheduled to see

them that day

• Reason for the treatment • Client should understand the expected benefits, and goals of the treatment,

prognosis, how long it may take to achieve them, etc

• Material effects, risks and side effects

• Alternatives to the treatment

• Consequences of declining the treatment

• Opportunity for questions/concerns

To Give Informed Consent

A client must not only understand the information, but also appreciate the consequences of the decision.

Example:

A client could understand that periodontal disease may have an

effect on the stability of their teeth. However, the client may not

understand that at some point periodontal disease will make teeth

so unstable that they cannot eat certain foods, tooth loss will occur

and it will be difficult for clients to maintain proper nutrition.

Types of Consent

• Informed consent can be written, recorded, or verbal.

• Since informed consent is a process, it requires a verbal discussion regardless of whether there is a written form involved. Written consent forms are used for certain procedures, such as surgical or endodontic procedures, or aggressive periodontal treatment programs .

• If the practice is using digital records only, there are two ways to obtain the patient’s (or guardian’s) signature for the patient record:

• Use a signature pad, which is a device that allows the patient’s signature to be transferred digitally into the record.

• Hard copy document to be signed by the patient, and then that document is scanned into the patient record.

• Oral consents may be satisfactory for routine procedures that you expect the patient to know about, such as a dental examination.

• Recommendation to use written consent documents for all treatment procedures that are invasive or present a high risk.

• If a written consent document is not used, the patient’s verbal consent should be documented in the patient chart. Box on the chart

Example of documentation of verbal consent:

Discussed the diagnosis of periodontal disease; purpose, description, benefits, and risks of the proposed treatment; alternative treatment options; the prognosis of no treatment; and costs. The client asked questions and demonstrates that he understands all information presented during the discussion. Informed consent was obtained for the attached treatment plan.

Refusal

Should be documented in the dental record and signed/initialed by the client

Examples:

Which of the following is correct regarding documentation in the

client record?

1. Entries should outline the ADPIE process of care model that

took place in a given appointment

2. Entries made in pencil can be erased provided that the

correct entry is completed at the same time

3. Entries made in ink can be corrected with White-out

4. Entries made in the treatment notes must include the

client’s insurance information

Examples:

Which of the following would be considered an omission error in

a client’s record?

1. Failure to record periodontal assessment data and a dental

hygiene diagnosis

2. Failure to document a dental hygiene care plan

3. Failure to document informed consent

4. All of the above

How long to keep records

• CDSS Document

• 6 years after the date of the last entry in the record

Message mailed to all dentists and dental hygienists

December

Joint Message

Often asked for advice and direction on how to correctly bill for dental hygiene treatment time.

Saskatchewan Oral Health Professions Conference Presentation

Frank Edwards September

• While the suggested fees are not obligatory, the use of correct procedure codes is.

• The dentist and dental hygienist must use the code that describes the actual service provided.

Fee Guide

Inappropriate billing could be considered fraudulent by third parties, dental regulators, bylaw enforcement agencies, or the courts.

• Intended to serve as a reference: a structure of fees which is fair and reasonable to the patient and to the dental practice.

• The suggested fees are not obligatory and each dentist is expected to determine independently the fees which will be charged for the services performed.

HOW ARE PER-UNIT-OF-TIME PROCEDURE CODES TO BE DETERMINED AND USED

In the case of per-unit-of-time procedures such as scaling and root planning, the code used must reflect the amount of time spent providing the service.

Time is measured in fifteen minute units. If a procedure takes a partial unit of time, (less than 8 minutes), the procedure code which corresponds to the half unit of time should be used. Where a half unit of time code does not exist, the code which corresponds to the next higher unit of time may be used and the dentist may adjust his/her usual and customary fee lower to reflect, in the billing, the actual time spent on the procedure.

HOW ARE PER-UNIT-OF-TIME PROCEDURE CODES TO BE DETERMINED AND USED

If multiple procedures are being performed in a fifteen minute time unit, the

procedure that should be billed is the predominant procedure in any unit (or half unit) of time.

Example: If you spend 4 minutes on OHI during a unit of scaling, this unit of time should be billed as scaling, because scaling is the predominant procedure. OHI would be the predominant procedure if it took more than 7½ minutes and thus this unit of time should then be billed as OHI, not scaling.

DENTAL HYGIENE TREATMENT TIME DEFINED

Procedure codes billed and time spent should be individualized to each patient. A standardized amount billed for all dental

hygiene appointments or to every patient is unacceptable and should be avoided.

Some offices have moved to a billing protocol where every client is charged the same thing to maximize billing per hygiene

hour. THIS SHOULD NOT BE DONE!!

Employer/practice protocols • Professional Responsibility • Ethics • Accountability


Dental hygiene treatment time is not just limited to "instrument on tooth time“

Treatment time is “all the time the caregiver attends

to the patient”.


The time billable as scaling or root planing would include the following:

Reviewing the chart and asking about the patient’s medical history; Assessing vital signs, which are necessary to prepare for the treatment; Intra-oral/extra-oral assessments; Oral cancer screenings; Probing, recording findings from periodontal assessments and other

dental hygiene treatment notes; Providing post-operative instructions to the patient, when required; and Administering a local anaesthetic, when required. Local anaesthetic

performed as part of dental hygiene treatment is not billable as a separate procedure.


In any appointment, the maximum time billable on a per-unit-of-time basis is

the time the patient is seated, less the time taken to do any separately billable procedures.

Example: • If a recall exam is done in your chair and it takes 8 minutes • And you do 4 BWs (takes 7 minutes) • There are only 45 minutes that can be billed for dental hygiene

treatment time: • 1 hour appt:

• Recall Exam (8 minutes) • 4 BWs (7 minutes) • 2 ½ units scaling (36 minutes) • Prophy (9 minutes) = 60 minutes


Examples of procedures that are not included in scaling or root planing time would be: Separately billable procedures such as examinations or radiographs (if

done in the hygiene chair), prophy, fluoride, OHI, desensitization or sealants;

Breakdown, disinfection and set up of the operatory; Idle time while the dental hygienist is waiting for the doctor to arrive to

perform an examination (i.e., when not performing any procedure or procedure related activity); or

Any remaining appointment time after the patient has been discharged and the time for administrative functions such as billing and reappointing the patient.


Operatory ‘prep’ time, like other administrative functions, is considered

part of general overhead and the recovery of these costs is built into all procedure fees.

Example: • Sharpening • Infection Control • Documentation

NOT billable time!!


Time spent measuring and/or recording oral/dental findings other than periodontal conditions would not be included in hygiene treatment time; this is part of the dentist’s exam and this time is billed to the patient in the exam fee, regardless of whether that exam is done at this appointment or at a subsequent appointment.

Examples: • Occlusion • Hard Tissue Charting • Possible caries

DO DENTAL HYGIENISTS NEED TO RECORD THE START AND STOP TIME FOR ALL PATIENT APPOINTMENTS?

The dental hygienist should record the time spent providing services that are based upon units of time; specifically the time spent scaling and root planning, polishing and/or desensitizing must be recorded. This time should include all the treatment time (excluding the time taken to perform procedures that are billed on a per-procedure basis such as fluoride, pit and fissure sealants, radiographs and the dentist’s recall exam).

Best practice is to record the number of minutes providing each of these services. Recording only as units may be confusing particularly when the office books in 10 minute units because procedure codes are always based on 15 minute units.

DO DENTAL HYGIENISTS NEED TO RECORD THE START AND STOP TIME FOR ALL PATIENT APPOINTMENTS?

The total time recorded for procedures that are billed as per-unit-of-time plus the actual time taken to perform procedures billed on a per-procedure basis should not exceed the total time the patient is in the chair.

Nor is it appropriate to round up several procedures so that the total time billed exceeds the time the patient is seated.

Acceptable 1 Hour appointment examples:

3 units scaling 40 minutes

Prophy 9 minutes

Fluoride 5 minutes

Total 54 minutes

3 ½ units scaling 53 minutes

½ Prophy 6 minutes

Total 59 minutes

Recall Exam 6 minutes

4 BWs 7 minutes


Prophy 8 minutes

Fluoride 5 minutes

Total 60 minutes

Unacceptable 1 Hour appointment examples:


Prophy 8 minutes

Fluoride 5 minutes

Total 66 minutes


Prophy 8 minutes

Total 61 minutes

Recall Exam 8 minutes

2 BWs 5 minutes

3 units scaling 38 minutes

Prophy 8 minutes

Fluoride 5 minutes

Total 64 minutes

Continuing Competency Program Guidelines

• All regulated professionals are required to maintain some form of Continuing Competency or Quality Assurance requirements:

• Continuing Education

• Portfolios

• Examination/Assessment

• Mandated by Government/Regulatory responsibility

• Means to ensure that professionals are remaining current in new technology, skills, knowledge

• Review of accomplishments (audits) demonstrate that regulatory body is ensuring safe, competent professionals

– Members require a minimum of 45 Continuing Competency

credits in a 3-year period • 5 credits provided in the 3rd year for completion of PL Tools

– Required for full, conditional or non-practising members

– A minimum of 30 credits to be obtained in the Dental Hygiene Practice Category

– Credit hours in excess of those required in a 3-year cycle cannot be carried forward to a subsequent period.

SDHA Credit Requirements

All continuing competency programs, courses or equivalent must have significant intellectual or practical content related

to the practice of dental hygiene or to the professional responsibility or ethical obligations of the member.


• Members are responsible for keeping track of their own continuing competency hours and for reporting those hours to the registrar’s office.

• If the activities/courses are put on by the CDSS, SDHA, SDAA or SDTA there will most often be a sign-in/sign-out sheet at the door that is automatically forwarded to the SDHA. If it is not sponsored by one of these organizations, but is largely attended, confirm with the facilitator that the sign-in/sign-out sheet will be forwarded.

• Members may be granted credits for courses or activities not sponsored by SDHA, however, will be asked to provide further information to the registrar. If members are unsure if courses will qualify for credit, prior approval should be obtained.

Reporting of Credits

Reporting of Credits

ALL FORMS ONLINE AT www.sdha.ca

Please Note:

ONLINE AT www.sdha.ca


Personal Learning Tool Forms (PL Tool) • It is a Saskatchewan registrants’ professional responsibility to determine

their specific continuing competency needs and to pursue activities that enable them to maintain competency in their dental hygiene practice.

• The PL Tool was developed to assist the SDHA membership in their self-determination of learning at continuing education opportunities and to aid application of the knowledge to Practice Standards.

• The CDHA/SDHA Practice Standards and SDHA Competencies apply to all aspects of our day-to-day practice. The Practice Standards are to be used by dental hygienists to assess dental hygiene practices and to identify learning goals that will direct continuing quality improvement activities.


Personal Learning Tool Forms (PL Tool)

• The function of the Personal Learning Tool (PL Tool) is to serve as

evidence that dental hygienists in Saskatchewan are following the Practice Standards of the profession. Each dental hygienist should maintain his/her own evidence of his/her own professional development.

• Each member will RETAIN COPIES of their completed Personal Learning Tool Forms for each three-year reporting period.


Personal Learning Tool Forms (PL Tool) • The Continuing Competency Committee will randomly audit

approximately 10% of dental hygienists’ PL Tool forms annually.

• The audits will be performed on a random selection of those members who are at the end of their three-year reporting periods.

• Those selected will have 2-3 months notice to submit their completed forms. The auditors will review the forms to ensure all the required evidence of continuing professional development has been included.

• Should any forms be incomplete, the dental hygienist will be given an opportunity to correct the deficiency.

PL Tool Changes

• 5 credits each 3 year reporting period for completion of forms, granted in 3rd year.

• Forms changed: – Question 1

– List a minimum of 3 Practice Standards/Competencies

– If audited, submit PL Tools for only 45 credits

http://www.sdha.ca/

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