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Do your clinical records support continuity of care?

In a dental/dental hygiene practice setting, a client may receive care from multiple RDHs over time. Maintaining clear, detailed clinical records is essential because it supports continuity of care. 

Continuity of care means that clients receive ongoing, coordinated, and consistent dental hygiene treatment over time, regardless of which RDH provides treatment. When documenting treatment, RDHs should ask themselves, “Could another RDH easily continue this client’s care based on my documentation?”

In other words, would another RDH be able to easily understand:

  • What I did?
  • Why I did it?
  • What are the next steps?

Keeping detailed clinical records is the best way to ensure a client’s continuity of care. This includes but is not limited to:

  • Completing and recording all the steps of the process of care.
  • Having a thorough medical and dental history present and recording any updates and changes at every appointment.
  • Conducting appropriate assessments in a timely manner and documenting the findings.
  • Not skipping relevant assessments simply because this may not be a regular client and/or you will not be treating them again (e.g., skipping a periodontal assessment when one has not been done in a while).
  • Evaluating, re-evaluating, updating and modifying treatment as required.
  • Recording relevant details of communication with clients, such as:
    • Refusal of consent for any services
    • Explanations of risks and benefits related to all treatment options
    • Preferences for treatment modalities (e.g. client does not like mint-flavoured polish, or client finds ultrasonic scaling too sensitive).

By maintaining detailed and clear clinical records, RDHs can ensure seamless treatment, avoid duplicating a client’s care plan, and complete services in a timely manner, all of which contribute to improved oral health outcomes for clients.

If you have any questions about record keeping, please get in touch with our Practice Advisor at advice@cdho.org or call 1-800-268-2346 (press 2).