CHAPTER 20 Dental Hygiene Care Plan and Evaluation

Karen M. Palleschi

Competencies

image Explain the purpose of the planning phase in the dental hygiene process of care and the client’s role in care plan development.
image Identify the sequence for developing a dental hygiene care plan and how each step relates to the dental hygiene diagnosis.
image Discuss the purpose of the evaluation phase of client care and its significance to the process of care and practitioner liability.
image Formulate a client-centered care plan from a dental hygiene diagnosis.

Care planning and evaluation are processes applied daily by the dental hygienist in practice. Both are integral to the process of care and dependent on the preceding phases of care, assessing and diagnosing. Integrating care planning and evaluating into dental hygiene care ensures a client-centered approach when treating clients. Dental hygienists must be competent in using principles of care planning and evaluation.

PLANNING

Planning is that phase of the process of care in which diagnosed client needs are prioritized, client goals and evaluative measures are established, and intervention strategies are determined (Figure 20-1). The purpose of the planning phase is to develop a plan of care that will result in the resolution of an oral health problem amenable to dental hygiene care, the prevention of a problem, or the promotion of oral and general health. Therefore care plan rather than treatment plan is intentionally used to denote the broad range of preventive, educational, therapeutic, and support services within the scope of dental hygiene practice. In keeping with standards of practice and evidence-based interventions, the dental hygienist engages the client in formulating a client-centered plan with clearly defined tangible outcomes.

image

Figure 20-1 Planning phase of the dental hygiene process of care.

To formulate a care plan the dental hygienist must effectively do the following:

image Use parameters or standards of dental hygiene care.
image Collect, analyze and interpret client data.
image Integrate evidence-based knowledge and theory, professional judgment, and the values of the client.
image Develop dental hygiene diagnoses, formulate client goals, and select supportive dental hygiene interventions.
image Synthesize this aforementioned information into a written plan.
image Communicate oral health needs to clients.
image Position the dental hygiene care plan within the context of the total dental treatment plan.

Dental Treatment Plan

The general dentist or dental specialist, develops a comprehensive dental treatment plan for the client. This plan includes the dental diagnosis; all essential phases of therapy to be carried out by the dentist, dental hygienist, and client to eliminate and control disease or promote health; and the prognosis. Components of a dental treatment plan are shown in Table 20-1. The dental hygiene care plan supports the overall dental plan. Ongoing collaboration between the dental hygienist, dentist, physician when warranted, and client is critical to attaining a successful outcome.

TABLE 20-1 Components of the Overall Dental Care Plan

Components Included in the Dental Hygiene Care Plan
Preliminary Phase: Emergency Care  
Relief of pain  
Laboratory tests for suspected pathology  
Emergency needs (e.g., treatment of periodontal or periapical abscess)  
Extraction of hopeless teeth  
Provisional replacement to restore function, as needed  
Phase I: Nonsurgical Therapy  
Client education and self-care instruction x
Nutritional counseling (e.g., caries prevention, tissue healing) x
Tobacco cessation x
Fluoride and remineralization therapy x
Placement of pit and fissure sealants x
Therapeutic periodontal debridement x
Hard-tissue desensitization x
Correction of restorative and prosthetic irritative factors, excavation of caries  
Antimicrobial (anti-infective) therapy (local or systemic) x
Occlusal therapy, minor orthodontics  
Selective coronal polishing x
Evaluation of Response to Nonsurgical Therapy  
Reassessment of gingival and periodontal health, hard and soft deposits, host response x
Review and reinforcement of self-care x
Phase II: Surgical Therapy  
Periodontal surgery  
Implant surgery  
Endodontic therapy  
Phase III: Restorative Therapy  
Restorative care and final management of dental caries
Fixed and removable prosthetics
  
Evaluation of response to restorative procedures (e.g., periodontal status, host response)  
Phase IV: Maintenance Therapy  
Supportive, preventive, and therapeutic periodontal maintenance therapy x
Self-care education x
Evaluation and recommendation of continued-care interval x

Adapted from Carranza FA, Takei HH: The treatment plan. In Newman MG, Takei HH, Klokkevold, PR, Carranza FA, eds: Carranza’s clinical periodontology, ed 10, St Louis, 2006, Saunders; Nield-Gehrig JS, Willmann DE: Decision-making during treatment planning. In Nield-Gehrig JS, Willmann DE: Foundations in periodontics for the dental hygienist, ed 2, Philadelphia, 2008, Lippincott Williams and Wilkins.

Dental Hygiene Care Plan1

The dental hygiene care plan is the written blueprint that directs the dental hygienist and client as they work together to meet the client’s oral health goals. Primarily the plan increases the likelihood that the oral healthcare team will work collaboratively to deliver client-centered, goal-oriented care. The plan facilitates the monitoring of client progress, ensures continuity of care, serves as a vehicle for communication among healthcare professionals, and increases the likelihood of high-quality care (Box 20-1).

BOX 20-1 Rationale for Developing a Formal Dental Hygiene Care Plan

• Individualize care.
• Focus care on priorities.
• Facilitate communication and collaboration among healthcare professionals.
• Establish client-centered goals.
• Provide foundation on which evaluation of interventions is based.
• Develop roadmap for implementing interventions that will achieve the desired outcome.
• Promote professional practice.

The dental hygiene care plan is written immediately after the assessment and diagnosis phases of the process of care and in conjunction with the overall dental treatment plan, prepared by the dentist. The care plan specifies the following:

image Dental hygiene diagnoses
image Client-centered goals
image Dental hygiene interventions
image Appointment schedule

During the planning phase of care, dental hygiene diagnoses are prioritized and each component of the care plan is sequentially developed and linked to the dental hygiene diagnoses. Establishing this link between the dental hygiene diagnosis, client goals, and dental hygiene interventions is critical to the outcome of the care plan (Figure 20-2). Each dental hygiene care facility may have its own care plan format to document assessment findings, dental hygiene diagnoses, client-centered goals, dental hygiene interventions, appointment schedule, and an evaluative statement of outcome. Although formats may differ, the critical point is that these components are documented in the client’s permanent record and are followed to ensure high-quality dental hygiene care. The plan may use standardized abbreviations and key phrases as specified in the policy manual of the healthcare institution with which the dental hygienist is affiliated (Box 20-2). Figure 19-3 in Chapter 19 is a dental hygiene care plan form for documenting unmet human needs.

image

Figure 20-2 Sequence for developing a care plan.

BOX 20-2 Characteristics of a Well-Written Dental Hygiene Care Plan

• Reflects goals of care to (1) develop and maintain the individual’s behaviors essential to oral health and the mastery of self-care and the environment; (2) prevent oral disease using primary, secondary, and tertiary preventive interventions; and (3) promote wellness
• Is consistent with client needs and readiness to change
• Identifies dental hygiene diagnoses, client goals, and interventions
• Is compatible with the dental treatment plan prepared by the dentist
• Identifies the dental hygienist’s responsibilities, if any, for fulfilling components of the dental treatment plan
• Reflects current standards of evidence-based care
• Meets the clients’s psychosociocultural and physical needs
• Reflects the dental hygienist’s role as clinician, educator, administrator or manager, researcher, and advocate
• Establishes priorities of care

Sequence of Dental Hygiene Care Plan Development

Linking the Diagnosis and the Care Plan

A dental hygiene diagnosis is the foundation for care plan development. Basing dental hygiene care plans on the dental hygiene diagnosis, rather than on oral symptoms alone, ensures that care will be comprehensive and focused on client needs. A care plan may include a single or multiple dental hygiene diagnoses.

A complete dental hygiene diagnosis includes a statement of the problem (unmet human needs related to oral health), cause of the problem (contributor), and signs and symptoms of the problem (evidence). By focusing on the contributors and evidence of the unmet human needs, the clinician is able to develop client goals and intervention strategies that will best meet the need or eliminate the problem. Therefore client care is individualized, as opposed to the same routine care being provided to all. Because signs and symptoms related to dental hygiene problems may have numerous causes, interventions must be carefully selected to ensure that the fundamental cause is being addressed in dental hygiene care. For example, a dental hygiene diagnosis of an unmet human need in the area of wholesome facial image may result from the following:

image Client dissatisfaction with the color of his or her teeth
image Client embarrassment because of a disfiguring malocclusion
image Middle-aged client’s loss of self-esteem associated with mobile teeth and oral malodor from chronic periodontal disease
image Nursing home resident who no longer wants to interact with friends and family because of lost dentures

These problems require the establishment of unique client goals and dental hygiene interventions to resolve them. Figure 20-3 uses the aforementioned examples as the basis for establishing client-centered goals and planning dental hygiene interventions that focus on the unique needs of the client who is dissatisfied with his tooth color.

image

Figure 20-3 Example of a dental hygiene diagnosis, goals, interventions, and evaluative statements for a client who wants whiter teeth.

Establishing Priorities1

In collaboration with the dentist, the dental hygienist considers the dental and dental hygiene diagnoses and determines their urgency. Priorities are based on the degree to which the dental hygiene diagnosis does the following:

image Threatens the client’s well-being; it is important to distinguish unmet needs that pose the greatest threat to client safety, health, and comfort from those that are non–life-threatening and/or related to a current oral disease
image Can be addressed simultaneously with other diagnoses
image Is a client priority, e.g., chief complaint

Once these criteria are applied to the dental hygiene diagnoses, the dental hygienist ranks the unmet human needs in priority to be addressed. Other than meeting the client’s unmet human need for safety (prevention of health risks), which in some instances requires emergency care or referral to a physician, dentists and dental hygienists would most likely identify the client’s ability to assume responsibility for oral health as a primary priority. Factors influencing how priorities are established include the following:

image Values, beliefs, and attitudes of the client
image Philosophy of the healthcare provider
image Goals of the collaborating dentist
image Health status of the client
image Whether the client is experiencing infection, discomfort, anxiety, or pain

Setting Goals1

A client-centered goal is a desired outcome that the client aims to achieve through specific dental hygiene intervention strategies to satisfy an unmet human need. These goals reflect the signs and reported symptoms of the client’s unmet human needs. By setting goals based on the dental hygiene diagnosis, a relationship is established that enables the clinician and client to measure the extent to which goals have been achieved in terms of changes in the client’s initial signs and symptoms.

A client-centered goal may address cognitive, psychomotor, affective, or oral health status needs:

image Cognitive goals target increases in the client’s knowledge. nPsychomotor goals reflect the client’s skill development and skill mastery.
image Affective goals address desired changes in client values, beliefs, and attitudes.
image Oral health status goals target the signs and symptoms of oral disease and reflect a desired health outcome achievable through dental hygiene interventions.

Knowledge and skill development alone may not correlate with client adherence to self-care. The client must internalize the desire and make modifications in behavior, so a variety of goals are necessary.

Writing Client-Centered Goals

Adopting a format for writing client-centered goals will simplify the task (Box 20-3). Each client-centered goal should have a subject, a verb, a criterion for measurement, and a time dimension for evaluation:

image The subject is the client or client’s caregiver.
image The verb is the action desired of the client to achieve the desired outcome; it is not the action of the dental hygienist.
image The criterion is the observable behavior or desired tangible outcome.
image Time dimension denotes when the client is to have achieved a goal. This target time may be a specific date or a statement (e.g., by next appointment, by the evaluation appointment, by end of treatment). Assigning a time frame to each client goal gives both the client and the clinician a point of reference. Clients need time to:
○ Internalize information
○ Practice new skills
○ Experience physical and attitudinal changes related to oral health and wellness
○ Assess the importance of these changes to their lifestyle
○ Adopt the new behavior

BOX 20-3 Guidelines for Writing Client-Centered Goals

Prepare each goal, or set of goals, from only one dental hygiene diagnosis.
Ensure that goals, if met, will resolve the problem reflected in the dental hygiene diagnosis.
Collaborate with dentist to ensure that the dental hygiene and dental care plans are mutually supportive.
Involve client in goal setting.
Validate that client values and is ready to achieve the delineated goals.
Write observable and measurable goals that include target times when each will be met by the client.
Use active verbs such as the following to denote client behavior expected in the goal:

affirm

attend

choose

communicate

complete

decrease

define

demonstrate

describe

detect

discuss

eliminate

exhibit

explain

finish

guide

increase

perform

plan

purchase

remove

replace

report

stop

use

verbalize

Goals evaluated too early restrict the clinician’s and the client’s ability to determine the impact of the care provided. At least one goal should be established for each dental hygiene diagnosis (Table 20-2).

TABLE 20-2 Some Dental Hygiene Diagnoses with Related Client-Centered Goals

Dental Hygiene Diagnosis Goals
Unmet human need for protection from health risk due to blood pressure elevated above normal limits as evidenced by a reading of 160/100 mm Hg. Client will report having blood pressure evaluated by physician before rescheduled visit on 10/5.
Unmet human need in wholesome facial image due to use of spit tobacco as evidenced by client dissatisfaction with stained teeth. Client will successfully complete a formal program for spit tobacco cessation by 12/30.
Unmet human need for skin and mucous membrane integrity of the head and neck due to subgingival biofilm accumulation in 4-mm pockets as evidenced by gingival bleeding. Client will exhibit a gingival bleeding score of no more than 2 by 6/15.

Involving the Client

Client goals are best established by the dental hygienist in collaboration with the client. Too often, individuals receiving care are referred to as “the Class II cavity preparation in treatment room 2” or “the advanced periodontal case at 4 pm.” These phrases communicate insensitivity to the individual, who is central in care. The oral healthcare professional who views the person as the focus of attention is more likely to establish a collaborative, co-therapeutic relationship with the client. This philosophy of care sets the stage for active client participation in identifying needs, readiness to change, priorities, goals, and interventions. Clients encouraged to participate in the process of care are more likely to communicate their wants, needs, and expectations than to relinquish decision making about their care to the dentist or dental hygienist. Individuals are more likely to express commitment to a care plan and their willingness to change if they shared in the development of goals, priorities, interventions, and appointment planning. Furthermore, when clients participate in care planning and believe that they have a key role in the success of the plan, compliance is augmented (Box 20-4).

BOX 20-4 Common Phrases to Maximize Client Involvement

• Here is a hand mirror. Let’s examine your mouth together.
• What was your primary reason for seeking dental hygiene care?
• Is this set of treatment priorities acceptable to you?
• Is this care plan acceptable to you?
• What would you like to achieve as a result of dental hygiene care?
• How will you feel if this goal is attained?
• Are you satisfied with the plan of care we just discussed?
• How important is your oral health?
• Where would you like me (the dental hygienist) to start first?
• When and where is it easiest for you to clean your mouth (or your dependent’s mouth)?
• Can you think of a better way that we can accomplish this goal?
• Let’s compare how your gingiva looks today with how it looked 2 weeks ago.
• What are you willing to do to keep your mouth healthy?

At times, specific goals are valued more highly by the dental hygienist than by the client. When this occurs, the dental hygienist explains the professional judgment and decision, with a clear message that the client’s readiness to change, wants, and needs are equally important to the overall plan. Although these points are important for obtaining client commitment and adherence to the final dental hygiene care plan, dental hygienists must also keep in mind that respecting the client’s role as a co-therapist and partner in decision making is an effective risk management strategy for avoiding legal problems.

Selecting Dental Hygiene Interventions1

Dental hygiene interventions are the evidence-based strategies, products, and procedures that if applied will reduce, eliminate, or prevent the oral health problem. Interventions, like client-centered goals, are linked to the dental hygiene diagnosis. However, interventions address the factors contributing to the client’s human need.

Various factors may contribute to a client’s unmet need for a biologically sound and functional dentition, including but not limited to:

image Lack of knowledge about dental caries process or its infectious, chronic nature
image Lack of knowledge about self-care for prevention of dental caries
image Lack of protective factors
image Skill deficit in oral self-care
image Low value on oral health
image Low self-esteem
image Inadequate financial resources
image Culture as a barrier to professional care
image Presence of other risk factors

Therefore not every client with a high caries risk is cared for in the same way. For dental hygiene care to achieve the desired outcomes, evidence-based interventions must specifically address the factors contributing to the client’s unmet human need. For example, a dental hygiene intervention for “lack of knowledge about self-care for the prevention of dental caries” may include educating the client on the benefits of self-applied fluoride agents or teaching a parent with active caries about vertical transmission of the infectious disease to the children.

Evidence-based interventions enable the clinician and client to achieve the proposed client-centered goals and resolve the client’s unmet human need. Therefore professional dental hygiene care involves the careful tailoring of interventions to meet the unique needs of the client, as directed by the dental hygiene diagnosis.

Appointment Schedule

Once the interventions have been decided, they must be put into action at planned appointments. The appointment schedule becomes a guide for implementing the proposed interventions and specifies the following:

image Number of visits
image Time needed for each visit
image Interventions to be implemented at each visit

Number of visits and sequencing of interventions at appointments vary among clinicians and clients. The following are considered when an appointment schedule is planned:

image Time needed for each intervention (e.g., self-care education, pain management)
image Logic of grouping interrelated procedures
image Status and severity of unmet human need
image Client’s tolerance for long sessions
image Client’s scheduling requirements (e.g., early morning only, time limitations)

When unmet client needs and proposed care plan goals are easily attainable, the related interventions may be implemented in one visit. When diagnoses, client goals, and interventions are complex, multiple appointments are indicated.

Scheduling time for educational interventions and the sequencing of self-care strategies must be given consideration during appointment planning. Too often client education is squeezed in at the end of an appointment as time permits. Effectively addressing the client’s cognitive, psychomotor, and affective needs will influence oral health outcomes and the client’s long-term responsibilities for self-care. Sequencing small increments of instruction into each visit may successfully shape the client’s self-care responsibilities. For example, multiple appointment care plans may spread client education over several visits to include time to review and reinforce previously introduced self-care behaviors. Box 20-5 suggests strategies for planning client self-care.

BOX 20-5 Strategies for Care Planning Self-Care Interventions

• Include self-care education in each visit.
• Link self-care education with related dental hygiene interventions.
• Consider variables such as client dexterity, skill, knowledge, disabilities, personal preferences, etc.
• Involve client during self-care instruction (e.g., have client demonstrate technique intraorally, clarify knowledge with open-ended questions, verbalize opinions).
• Encourage client success, e.g., take small steps, review, monitor, remediate, reinforce.
• Include parent or caregiver when instructing a young child or client with special needs.
• Validate client’s ability to obtain recommended oral health aids (e.g., cost, availability).
• Educate client to accept responsibility for health maintenance.

Care Plan Presentation

Before presenting the care plan to the client, the dental hygienist assesses the comprehensiveness of the plan by answering the following questions:

1. Does the care plan address the client’s unmet human needs relative to oral health that are amenable to or affect the outcomes of dental hygiene care?
2. What are the cultural beliefs and behaviors of the client?
3. What might the client’s response be to the care plan (e.g., interest, commitment, worry, fear, discontent, lack of enthusiasm)?
4. How should the care plan be presented to elicit client cooperation?
5. How can client involvement be maximized?
6. What is the dental hygienist’s response if the client refuses care?

When the dental hygienist is satisfied with the completeness of the dental hygiene care plan, the plan is discussed with the client. The dental hygienist must explain all aspects of the care plan and involve the client in the discussion. Presentation and discussion of the dental hygiene care plan include the following:

image Nature of the condition
image Proposed care plan
image Risks involved (if any)
image Potential for failure
image Expected outcomes if the problem goes untreated
image Alternative procedures

Once agreed on in writing by the client, the care plan becomes a legal contract between the dental hygienist and the client.

Most consumers expect to participate in decision making regarding their healthcare needs and know they have the right to accept or refuse services. If the care plan is to achieve the desired outcomes, both the clinician and client must support it. Therefore the care plan is presented to the client before preventive and therapeutic dental hygiene services are implemented. Failure to discuss the care plan with the client can result in services being performed without the client’s knowledge or informed consent. Also, the client may not recognize the importance of self-care or may have unrealistic expectations of care.

Informed Consent

The process of informed consent is the client’s acceptance of care after a discussion with the healthcare provider regarding the proposed care plan and risks of not receiving care (Figure 20-4). Informed consent should not be viewed as a one-time activity but as an ongoing process in which the client is continuously reinformed and reminded of the terms of care. For informed consent to be achieved, the client must be knowledgeable about what the healthcare provider plans to do, have enough information to make a rational choice, and give permission for the plan to be carried out. The client must:

image Give consent for a specific treatment
image Give consent for a procedure that is legal
image Give consent under truthful conditions (e.g., the consent cannot be obtained through fraud, deceit, misrepresentation, or trickery)
image

Figure 20-4 Sample informed consent form.

In addition to the client being informed, the client must be legally competent to give consent for care. For example, in the case of a minor, consent must be given by the parent or legal guardian (healthcare decision maker). Although implied consent is given when a client voluntarily comes to the oral care setting and sits in the dental chair, this consent applies only to the assessment, diagnosis, and planning components of the dental hygiene process of care. The dental hygienist cannot assume that the client consents to any further care. The client’s expressed consent, which is given verbally or in writing, must be obtained for additional services to be implemented.

Informed Refusal

Given all information necessary for a client to make an informed decision, the possibility exists that a client may decline all or part of the proposed care plan, such as in the following situations:

image Refusal of fluoride therapy, radiographs, or antimicrobial agents
image Noncompliance with referral to a dental specialist or physician
image Nonadherence to a specific oral self-care recommendation
image Decision to terminate care before goal attainment
image Refusal to give up a behavior that increases the risk of periodontal disease progression (e.g., tobacco use)

Although troubling, client refusal must be analyzed to determine how or why the client arrived at that decision. The clinician should engage the client in conversation, listen, and evaluate the client’s reasons for declining the services. At this time the clinician may choose to reopen the discussion of treatment needs. If after this discussion the client makes an informed refusal, the clinician should have the client sign a declaration of informed refusal (Figure 20-5). A copy of the refusal form can be given to the client, and a copy kept in the client’s record. Box 20-6 offers suggested client reasons for refusal of care, clinician actions, and documentation of informed refusal as a legal risk management strategy.

image

Figure 20-5 Sample informed refusal form.

BOX 20-6 Client Reasons for Refusal of Care, Dental Hygiene Actions, and Documentation of Informed Refusal

Client Reasons Clinician Actions Documentation
Cost of service
Fear of pain
Lack of understanding
Low value placed on dental care
Lack of dental insurance coverage
Acknowledge client’s concerns
Clarify proposed plan of care
Discuss consequences of not receiving recommended care
Recommend alternative treatment options when appropriate
Include brief explanation of recommended care
Identify specific treatment procedure being declined
List risks and consequences to client’s health without treatment
Indicate date of informed refusal
Include signatures of client, dentist, and a witness

In some situations the client may request care that, in the opinion of the dentist or dental hygienist, is unwarranted, inappropriate, or dangerous. If the dental hygienist is faced with this dilemma, she or he should refuse to provide the care and should encourage the client to seek a second professional opinion. As a rule, the client should never be allowed to dictate treatment.

See Procedure 20-1 for steps for dental hygiene planning.

Procedure 20-1 DENTAL HYGIENE CARE PLANNING

STEPS

1. Link care plan to dental hygiene diagnoses.
2. Establish priorities of need.
3. Set client-centered goals.
4. Select dental hygiene interventions.
5. Establish an appointment schedule.
6. Present the dental hygiene care plan.
7. Document in ink the completion of this service in the client’s record under “Services Rendered” and date the entry (e.g., “Care plan was developed to address the client’s unmet human need, care plan was presented and discussed with the client. Client asked clarifying questions before acceptance of care plan.”).

EVALUATION

Goal of Evaluation

The goal of evaluation is to document achievement of desired therapeutic outcomes, that is, fulfillment of the client’s unmet human needs related to oral health and wellness. Evaluation is a critical component to the success of dental hygiene care. Specifically, evaluation allows the clinician to measure the short-term achievement of client-centered goals as well as to anticipate the client’s long-term prognosis in maintaining the goals achieved.

Although evaluation is indicated as the final phase of the dental hygiene process, evaluation is inherently linked to each phase of care (Figure 20-6). The foundation for establishing an evaluation strategy consists of the baseline signs and symptoms that support the dental hygiene diagnosis. Evaluation strategies are defined by the client-centered goals during the planning phase and applied during the implementation of care to support the client in achieving a desired outcome.

image

Figure 20-6 Evaluation phase of the dental hygiene process.

As the appointment schedule is put into action and interventions are implemented, the clinician continually measures client progress toward achieving the goals, that is, the desired outcome. Evaluation includes monitoring (reassessing) the client’s goal attainment, that is, oral self-care behaviors, indicators of oral health and disease, and adherence to professional recommendations. Both the dental hygienist and the client have an active role in this process. For example, a dental hygienist may have performed an intervention competently, but if the intervention or therapy was unsuccessful at helping the client achieve the desired goal, a new strategy must be considered. Therefore evaluation of a client’s progress toward achieving a desired outcome is ongoing so that the clinician can do the following:

image Modify the plan because the client is having difficulty in achieving the goal
image Modify the plan because the client is not ready to achieve the goal
image Continue the plan because the client needs more time to achieve the goal
image Terminate the plan of care because the client has achieved the goal

Failure to evaluate the client can lead to what has been referred to as supervised neglect. Supervised neglect occurs when the client continues to require further dental hygiene care to achieve higher levels of oral wellness or to prevent or control oral disease progression, yet the client has been erroneously discharged from care thinking that a healthy state was achieved. Supervised neglect can occur in practices that have a one-approach-fits-all philosophy, manifested by employer statements such as the following:

image “Just do what you can in the time allotted.”
image “Do your best given the schedule.”
image “Everyone in this office gets a prophy and four bitewings.”
image “Everyone gets a professional topical fluoride treatment.”
image “Everyone gets a toothbrush only.”

In these situations the focus of care is task-oriented rather than client-centered. The emphasis is on completing the mechanics of a procedure, without considering the needs of the client, risk factors, and the influences of care on the client’s health status. In contrast, the focus of the dental hygiene process of care is the client and satisfying the client’s unmet human need. When the desired outcomes have been satisfied, a continued-care cycle is recommended to reactivate the process of care. Integrating evaluation into care demonstrates the dental hygienist’s commitment to achievement of the desired client outcomes. Evaluation does not meet every person’s need, but it provides assurance that unmet needs will not be overlooked or neglected.

Evaluation of Client-Centered Goals

Evaluation of client-centered goals determines whether dental hygiene care has achieved the client’s unmet human need. Evaluation methods should reflect the intent of the goal statement (e.g., cognitive, psychomotor, affective, or oral health status). An evaluation strategy may be as follows:

image Asking the client open-ended questions to measure acquisition of new knowledge (cognitive)
image Having the client demonstrate a newly learned interdental cleaning technique (psychomotor)
image Having the client report a behavior change, such as smoking fewer cigarettes (affective)
image Showing the client clinical improvements in oral health (e.g., decrease in probing depth, elimination of bleeding points, no new carious lesions) (oral health status)

Each client-centered goal is judged to determine the degree to which it has been achieved (Figure 20-7). Based on the new findings the dental hygienist determines one of the following outcomes:

image Goal met
image Goal partially met
image Goal not met
image

Figure 20-7 Components of an evaluative statement.

A written evaluative statement includes the dental hygienist’s decision on the degree to which the goal was achieved and concrete evidence that supports the decision. This statement is recorded in the client’s permanent record, signed, and dated by the dental hygienist. Samples of evaluative statements as they relate to a dental hygiene diagnosis and client goal are displayed in Table 20-3.

TABLE 20-3 Sample of Evaluative Statements as Related to the Dental Hygiene Diagnosis and Client-Centered Goal Statements

Dental Hygiene Diagnosis Goal Statement Evaluative Statement
Unmet human need for responsibility for oral health due to impaired physical ability as evidenced by a plaque-free index score of 30%.
Client will use a manual toothbrush modified with an enlarged, elongated handle at least once daily by 11/1.
Client will increase plaque-free index score by 11/1.
 11/1 Goals met. Client reported using modified toothbrush twice daily, and plaque-free index has increased to 80%.
Unmet human need for wholesome facial image due to wearing a denture and halitosis as evidenced by client’s concern with appearance of dentures, and client states that spouse complains she has frequent bad breath.
Client will meet at least two other individuals who successfully wear dentures by 12/1.
Client will clean dentures, tongue, and oral cavity with appropriate brushes and dentifrice by 11/25.
Client will use an ADA-accepted antimicrobial mouth rinse twice daily for 30 seconds by 11/25.
12/5 Goal partially met. Client met one person who successfully wears dentures and verbalized that the dentures looked natural.
11/25 Goal met. Client reported cleaning and rinsing mouth twice daily as directed and that spouse no longer complains about her bad breath.
Unmet human need for conceptualization and problem solving due to a knowledge deficit about the periodontal disease process as evidenced by bleeding on probing and attachment loss. Client will verbalize the periodontal disease process and identify oral biofilm as a prime causative agent by 9/20. 9/20 Goal met. Client can describe the role of oral biofilm and the periodontal disease process.
Unmet human need for biologically sound dentition due to infrequent dental visits as evidenced by signs of four carious lesions. Client will follow up on a referral made to the dentist of record and have the four carious lesions diagnosed and restored by 8/1. 8/15 Goal not met. Client canceled dental appointment.
Unmet human need for skin and mucous membrane integrity of the head and neck due to inadequate self-care as evidenced by gingival bleeding. Client will decrease bleeding by 75% by 5/8. 5/10 Goal met. Client no longer shows clinical signs of gingival bleeding.

Failure to evaluate the client’s status after care leaves the clinician unaware of the impact that the care may or may not have had. From a legal perspective, failure to evaluate the outcome of care may be grounds for negligence (malpractice). Unknown to the clinician and the client, the client’s oral health knowledge, behaviors, oral health status, or values may still be contributing to an oral health deficit. When a dental hygienist completes the cycle of care by measuring the extent to which client goals have been achieved and recommending continued care based on the outcome, the dental hygienist demonstrates professional practice.

Factors Influencing Client Goal Attainment

Characteristics of the client, dental hygienist, and clinical environment interact to enhance or hinder attainment of client goals. The astute dental hygienist identifies both positive and negative factors that may affect goal attainment. To facilitate the desired oral health outcome, positive factors are reinforced and negative factors managed.

Positive factors include:

image A client who values oral health, is motivated, and has a sense of inquiry
image A dental hygienist who maintains an evidence-based practice
image A work environment that values high-quality healthcare and offers incentives for care that meet or exceed recognized standards of practice

Table 20-4 presents common variables that can detract from quality of care. Possible dental hygiene responses are presented to initiate thinking about overcoming factors that impede goal attainment.

TABLE 20-4 Factors That May Detract from the Quality of Dental Hygiene Care

Factors Possible Dental Hygiene Action
Client Variables  
Client who refuses to cooperate with therapeutic regimen
• Determine underlying reason for observed behavior and client readiness to change; consider possible socioethnocultural factors.
• Counsel and educate appropriately.
Client who rarely communicates needs
• Encourage client to ask questions.
• Be nondirective in the educational approach.
• Involve primary caregiver, family, or interpreter in communication process.
Dental Hygiene Variables  
Dental hygienist who gives 200% of self when others do not
• Learn to leave work on time, avoid assuming work of others, leave work-related concerns at the workplace.
• Resolve work-related problems positively; seek strategies that improve motivation and morale of colleagues and self.
• View problems as challenges rather than insurmountable obstacles.
• Develop a realistic sense of what can be accomplished in amount of time given.
• When resources do not permit high-quality care and strategies do not result in positive change, explore other employment options.
Dental hygienist is bored
• Seek avenues for growth and development; participate in staff development and continuing education; identify a project and become involved; initiate strategies that result in positive change.
• Evaluate long-term career goals; seek advanced degrees.
• Participate in professional associations.
• Search for new position.
Dental hygienist is under stress from outside concerns (e.g., illness or death of significant others; marriage, childbirth, divorce, separation; role conflict as professional, parent, spouse; significant life changes)
• Evaluate whether this is the exception or the rule.
• Assess whether work performance is less than optimal.
• May need to reduce work hours rather than “cheat” clients.
• Seek counseling.
Environmental Variables  
Inadequate supplies and equipment
• Document problems with supplies and equipment.
• Identify specific supply and equipment needs and discuss with employer.
Inadequate time allotted to providehigh-quality care
• Identify and record type of dental hygiene care required. Relate client needs and outcomes to level of care provided. Document how more time can improve client outcomes.
• Discuss with employer.
Inadequate respect, recognition, and reward from employer
• Document incidents when respect, recognition, or reward were withheld.
• Talk with employer about specific incidents.
• Give employer suggestions on how situation can be improved.
• Search for new position.
• Initiate new policies, procedures, and training in the workplace.

Adapted from Taylor C, Lillis C, LeMone P, Tynn P: Fundamentals of nursing, ed 6, Philadelphia, 2008, Lippincott Williams and Wilkins.

Modifying or Terminating the Care Plan

When evaluation reveals that the client has made little progress toward goal attainment (i.e., goal partially met or goal not met), the dental hygienist reassesses the client’s readiness to change, attitudes, beliefs, and practices, and new findings are discussed with the dentist. Implications of these findings may lead to new diagnoses, revised goals, and alternative interventions. Client reassessment identifies barriers that continue to contribute to the client’s unmet human need, such as:

image Improperly developed client goals; goals that, if achieved, do not guarantee problem resolution
image Unrealistic goals for the client to achieve; unmeasurable goals
image Care plan that does not specifically address the client’s goals and unique socioethnocultural characteristics; plan contains only general information
image Care plan that has not been individualized
image Failure to evaluate
image Inadequate documentation

Once it is clear why the client has failed to achieve goals, the evaluative statement can be used to redirect the care plan.

When client goals have been met and no new problems identified, the dental hygienist and client have achieved the outcome of care. The care plan is terminated, and responsibility for continued oral health falls on the individual. Written and verbal instructions are given to the client to take home, and signs and symptoms of any possible future problems should be clearly understood by the client.

Dental Hygiene Prognosis and Continued Care

At termination of the care plan, a new process-of-care cycle is recommended to the client for continued care. A continued-care interval that will support the client’s efforts to maintain the oral health status achieved during active therapy is determined. Each continued-care visit begins with the reassessment of the client’s oral health to provide evidence of the long-term success of the previous care plan and need for supportive care. The dental hygienist determines the cycle of periodic reassessment and continued care from the client’s prognosis.

The dental hygiene prognosis is contingent on the following:

image Overall appraisal of the evaluative statements
image Client’s continued adherence to recommended self-care
image Level of optimum oral health achieved

A favorable prognosis occurs when risk for a new disease or recurrence of the previous conditions is low. A prognosis is guarded when risk for a new disease or recurrence of the previous condition is moderate to high.

Client-centered goals may be successfully achieved during active therapy; however, the prognosis may be guarded because of risk factors such as smoking or an uncontrolled systemic disease. Therefore the client and dental hygienist would select a frequent continued care interval to monitor oral health. Periodically the continued care plan is reviewed and adjusted to meet client needs. Continued-care appointments are scheduled at 2- to 12-month intervals based on client need.

Documentation of Services Rendered

A legal risk management strategy is to document the process of care in each client’s permanent dental record.2,3 Documentation that demonstrates a relationship among assessment, diagnosis, client-centered care plan, and evaluative statement of outcome is evidence that the services rendered reflected client needs. Documentation in the client record is the best defense against a client’s accusation of negligence (Figure 20-8).

image

Figure 20-8 Services rendered notes with an informed refusal documented.

Documentation of services rendered represents a written, legal record of all services performed for the client. Services should be recorded in the client record at the time they are performed. Entries are written in narrative form and describe relevant events of client care. All entries must be accurate and factual and provide enough detail to describe how the client progressed through the each phase of care to attain the proposed desired outcome. The narrative of services rendered and the client’s response to those services should be documented by the clinician who performed the services, signed, and dated. The example in Table 20-5 lists care planning and evaluation services that should be in the client’s record under “services rendered.”

TABLE 20-5 Guidelines for Documenting Planning and Evaluation in Client Records

Services Rendered Evidence of Services Rendered
Assessment Include demographic client data; personal, medical, dental, pharmacologic health history; vital signs; head and neck examination findings; dental and periodontal examination findings; oral self-care practices; client chief concern; client readiness to change; oral habits
Dental hygiene diagnosis Include a written statement of client need supported by related clinical evidence and contributing factors
Care plan
Include the proposed care plan and a written statement of client-centered goals, evidence-based interventions, and supportive appointment schedule
Summarize client involvement in development of care plan
Presentation of care plan to client Document client-clinician discussion of proposed care plan, valid informed consent and/or informed refusal
Implementation of care plan
Detail implementation of all care provided in chronologic order of appointments (e.g., client self-care education, cognitive and psychomotor skill development, adherence with recommendations; oral self-care aids dispensed for home use; client-clinician interactions; periodontal debridement; anesthesia)
Include the client’s adherence to the appointment schedule (e.g., late arrival, canceled, failed appointments) and when appointment was rescheduled
Record confirmation of appointments by phone, mail, or electronic communication
Record a narrative of clinician’s periodic reassessment to monitor progress toward achieving proposed outcomes
Record recommended continued-care interval and referral; indicate that this was discussed with client
Evaluative statement of outcome
Record complete evaluative statement of outcome and summary of evaluation methodology
Describe clinician action based on outcome of care
Indicate that outcome and prognosis were discussed with client
Date and signature of clinician Conclude each entry with date the service was provided (e.g., month/day/year) and signature of clinician who provided the service and completed the documentation of the services rendered (they should be the same person)

Scenarios 20-1 and 20-2 and care plans are provided as examples.

image SCENARIO 20-1 CLIENT WITH PLAQUE-INDUCED GINGIVITIS AND DENTAL CARIES AND SAMPLE DENTAL HYGIENE CARE PLAN

Susie S., a healthy 19-year-old single woman without dental insurance, is a second-year student living at the local university. Her last preventive dental appointment was 2 years ago and included a prophylaxis and four bitewing radiographs. She brushes twice daily with fluoride toothpaste and flosses occasionally. Her chief complaint is “I hate the brown stain on my teeth.”

Clinical assessment reveals soft tissues within normal limits, Class I malocclusion with a slight anterior overbite, and crowding in mandibular anteriors. Gingival evaluation indicates localized slight papillary inflammation, sulcus depths within 3 mm, no attachment loss, and slight bleeding on probing in sextant 5. Plaque-free index is 85%. Dental examination indicates that 30 teeth are present, including partially erupted third molars (No. 17/ No. 32), extrinsic brown stain from coffee, and slight lingual and proximal calculus in sextant 5. No restorations are present; molars have pit-and-fissure sealants. Bitewing radiographs reveal Class II carious lesions on the mesial surface of teeth 2 and 15 and incipient carious lesions on the mesial surface of teeth 19 and 30. Susie reports that she drinks three to four cups of coffee with 2 teaspoons of sugar daily.

Dental Hygiene Client Goals Interventions Evaluation
Dental Hygiene Diagnosis
Unmet human need for skin and mucous membrane integrity of head and neck due to anterior malocclusion, plaque retention in sextant 5 as evidenced by localized papillary inflammation, bleeding on probing, plaque-free score of 85%
The Client Will:    
Demonstrate proper flossing technique by end of appointment
Eliminate bleeding and inflammation in sextant 5 by next continued-care visit
Instruct client on relationship between oral biofilm and gingival inflammation.
Review client’s flossing skills.
Perform root debridement.
Goal met, client’s flossing technique modified.
Goal met, no evidence of bleeding or inflammation.
Dental Hygiene Diagnosis
Unmet human need for biologically sound and functional dentition due to frequent coffee and sucrose intake as evidenced by smooth surface carious lesions and extrinsic stain
The Client Will:    
Decrease frequency of sucrose and coffee intake by choosing a noncariogenic coffee sweetener or an alternative beverage with a noncariogenic sweetener by next continued-care visit
Use daily Rx brush-on 1.1% sodium fluoride and therapeutic doses of xylitol to decrease risk for future smooth-surface carious lesions by next continued-care visit
Have current carious lesions restored by next continued-care visit
Use a 0.12% chlorhexidine mouth rinse twice daily for 2 weeks after the restorations are placed to eliminate infection from Streptococcus mutans (do not use fluoride at this time)
Instruct client on impact of oral biofilm and frequent sucrose exposure to the caries process.
Instruct client on role of fluoride, chlorhexidine, and xylitol in prevention of caries risk.
Perform selective coronal polishing to remove extrinsic stain.
Refer to dentist of record for restorative treatment.
Recommend use of power toothbrush and an ADA-approved whitening toothpaste to control stain.
Goal met, carious lesions restored and no evidence of new lesions.
Goal met, client reports using daily Rx brush-on 1.1% sodium fluoride, therapeutic levels of xylitol, and noncariogenic sweetener.
Goal met, client reports completing 2-week regimen of 0.12% chlorhexidine gluconate.

APPOINTMENT SCHEDULE

Appointment 1 (50 minutes) CDT-2007-2008 Procedure Code
Initial personal, medical, dental, pharmacologic health history, measure vital signs; perform comprehensive oral assessment: head and neck, dental and periodontal; determine plaque-free or gingival index. D0150
Bitewing radiographs: four films. D0274
Inform client of clinical findings, diagnosis, and recommended care plan; obtain informed consent (or informed refusal).  
Oral self-care instruction: flossing.
Client education: oral biofilm and gingival health and caries process, benefits of daily fluoride to prevent smooth surface caries, benefits of a power toothbrush and whitening toothpaste. Use of chlorhexidine mouth rinse to eliminate source of caries infection. Discuss need to keep the chlorhexidine rinse and fluoride separate.
 D1330
Adult prophylaxis: full-mouth debridement, selective coronal polishing with mild abrasive. D1110
Continued-care interval: 6 months.  

image SCENARIO 20-2 CLIENT WITH PLAQUE-INDUCED GINGIVITIS MODIFIED BY SYSTEMIC FACTORS (PREGNANCY-ASSOCIATED GINGIVITIS) AND SAMPLE DENTAL HYGIENE CARE PLAN

Renee B. is a 29-year-old married woman with a 5-year-old child. Renee, 8 months pregnant and in good health, is taking Pepcid at bedtime for heartburn. She reports that her pregnancy is becoming uncomfortable.

Her last oral prophylaxis was 6 months ago and included oral hygiene instruction. Full-mouth radiographs were taken 1 year ago, and findings were within normal limits. She brushes once daily and flosses sometimes. Her chief complaint is that “My gums are bleeding when I brush and I always have a bad taste in my mouth.”

Clinical examination reveals soft tissues within normal limits, Class I malocclusion, generalized moderate marginal gingival erythema and edema, moderately bulbous interdental papilla, spontaneous heavy bleeding on probing, and probing depths of 4 to 5 mm with no attachment loss evident. Plaque-free index is 75.8%. Generalized subgingival calculus can be felt with the explorer and probe; supragingival calculus is visible on the mandibular anterior lingual teeth and facial surfaceof the maxillary molars. Dental examination reveals 28 teeth present (third molars were previously extracted) and multiple Class I and II amalgam restorations.

Dental Hygiene Client Goal Interventions Evaluation
Dental Hygiene Diagnosis
Unmet human need for conceptualization and problem solving due to client’s lack of knowledge about pathogenicity of oral biofilm as evidenced by the client’s bleeding gums when brushing
The Client Will:    
Explain composition of oral biofilm and impact on soft tissue and halitosis by 4/16
Verbalize how pregnancy can enhance gingivitis in the presence of oral biofilm by 4/16
Instruct client on composition of oral biofilm and impact on gingival tissues, tongue, and halitosis.
Instruct client on how pregnancy can enhance the incidence of gingivitis and periodontal disease progression, and how premature birth and low birthweight babies are linked to oral inflammation.
Goal met, client verbalized role of oral biofilm and effects on oral health.
Goal met, client explained pregnancy-associated gingivitis and how oral inflammation may be linked to preterm birth.
Dental Hygiene Diagnosis
Unmet human need for wholesome facial image due to plaque retention plus elevated hormone levels as evidenced by plaque-free index of 75.8%, gingivitis, and client’s concern about bad taste in her mouth and bad breath
The Client Will:    
Recognize the importance of daily management of oral biofilm for oral and systemic health by 4/26
Use an ADA-accepted antimicrobial mouth rinse twice daily to control oral biofilm and gingivitis by 4/26
Increase plaque-free index score to 90% by 4/26
Assist client in identifying plaque-retentive sites with bleeding points and disclosing agent.
Instruct client on the value of using an ADA-accepted mouth rinse to help control plaque and gingivitis.
Goal met, client reports daily flossing, mouth rinsing, and extended brushing time. Client also reports that the bad taste in her mouth is gone.
Goal met, client increased plaque-free index score to 95%.
Dental Hygiene Diagnosis
Unmet human need for skin and mucous membrane integrity of the head and neck due to plaque retention, infrequent flossing, and hormones associated with pregnancy as evidenced by gingival pockets, spontaneous bleeding
The Client Will:    
Decrease bleeding by 80% by 5/10
Decrease probing depths by 1 mm by 5/10
Instruct client on modified Bass toothbrushing.
Use sulcus toothbrush for the disruption of subgingival plaque biofilm.
Instruct client on flossing to disrupt proximal bacterial plaque biofilm.
Instruct client on use of an ADA-accepted antimicrobial dentifrice and mouth rinse to control plaque and gingivitis.
Perform therapeutic periodontal debridement: one visit for quadrants 1 and 4; second visit for quadrants 2 and 3.
Perform selective coronal polishing.
Goal partially met, bleeding points decreased by 70%.
Goal met, decreased gingival pockets by 1 mm.
Dental Hygiene Diagnosis
Unmet human need for protection from health risk due to risk of orthostatic hypotension as evidenced by client report that her pregnancy is becoming uncomfortable in the eighth month
The Client Will:
Identify comfortable chair position at each dental hygiene appointment to prevent orthostatic hypotension Position client in semi-upright position (45-degree angle) to alleviate fetal pressure on vena cava. Give client a pillow placed under the right hip while she is in chair. Goal met, client was asymptomatic of orthostatic hypotension during appointment.

APPOINTMENT SCHEDULE

Phase I: Nonsurgical Therapy Appointment 1 (1 hour)—4/16 CDT-2007-2008 Procedure Code
Update personal, health, dental, pharmacologic health history; measure vital signs; perform comprehensive oral evaluation: head and neck, dental, and periodontal; determine plaque-free index. D0150
Inform client of diagnosis and recommended care plan, including clinical findings, and obtain informed consent.  
Oral self-care instruction: modified Bass toothbrushing technique.
Client education: oral biofilm, gingivitis, halitosis, hormone-influenced gingivitis. Instruct client on use of an ADA-accepted antimicrobial dentifrice and mouth rinse to control plaque and gingivitis.
 D1330
Therapeutic periodontal debridement of quadrants 1 and 4. D4341
Appointment 2 (1 hour)—4/26  
Update health history and measure vital signs. Assess tissue response to self-care and periodontal debridement of quadrants 1 and 4, determine plaque-free index.  
Self-care instruction: review toothbrushing if needed and instruct on flossing. D1330
Therapeutic periodontal debridement of quadrants 2 and 3. D4341
Phase I: Evaluation of Response to Nonsurgical Therapy Appointment 3 (1 hour)—5/10  
Update health history and measure vital signs. Assess all quadrants for tissue response to self-care and periodontal debridement, determine plaque-free index. D0120
Review and reinforce oral self-care.
In preparation for new baby, dispense literature on preventive oral health for infants, vertical transmission of caries from mother to infant, early childhood caries.
 D1330
Adult prophylaxis to remove residual calculus (if any) and extrinsic stain with mild abrasive. D1110
Continued-care interval: 3 months.  

Additional scenarios are found on the image website:

image Preliminary Phase: Emergency Care
image Phase I: Nonsurgical Therapy
image Phase I: Evaluation of Nonsurgical Therapy
image Phase IV: Maintenance Therapy

See Procedure 20-2 for steps for evaluation of care.

Procedure 20-2 EVALUATION OF CARE

STEPS

1. Identify evaluative criteria and expected outcomes of care.
2. Collect evidence to determine whether goals are being are met.
3. Interpret and summarize the findings.
4. Write an evaluative statement.
5. Propose continued care options.
6. Document in ink the completion of this service in the client’s record under “Services Rendered” and date the entry; for example, “Updated client health history, reassessed client for changes in oral health status and oral health skills. Goals Met: Gingival and periodontal assessment indicated that the gingival tissue is pinker and firmer, no bleeding upon probing. Reassessed client’s flossing technique and client is competent. Client reports adherence to oral self-care recommendations. Continued-care interval: 6 months.”

CLIENT EDUCATION TIPS

image Explain the importance of developing a care plan.
image Explain how the dental hygiene care plan is integrated with the overall dental care plan.
image Incorporate client’s chief complaint, readiness to change, goals, needs, preferences, and values into the care plan.
image Involve client in the development of client-centered goals (augments commitment).
image Explain that clinical outcomes of care will be related to the original goals.
image Reinforce the dental hygienist and client partnership as co-therapists to achieve client-centered goals.

LEGAL, ETHICAL, AND SAFETY ISSUES

image Inherent in the process of care is the legal and ethical responsibility of healthcare providers to do the following:
Complete a comprehensive assessment of client unmet need.
Formulate a diagnosis and care plan based on that assessment.
Communicate the recommended care plan to the client.
Secure informed consent before implementing the care plan.
Implement the care plan.
Evaluate the outcome of care.
Recommend a continued-care schedule.
image Keep adequate client records that are legible, dated, and signed with the title of the individual making the entry.
image Document clinical and radiographic findings as evidence that the diagnosis and care plan are based on client needs.
image Provide evidence of medical consultation, when needed, and written response with information requested.
image Provide evidence of informed consent before implementation of care, signed and dated.
image Provide evidence of informed refusal when client refuses care or recommendations, signed and dated.
image Document self-care education, status of client compliance, failed or canceled appointments, postoperative instructions provided, modifications made in care plan and supportive facts, referrals, and continued-care schedule.
image Never release client record without written authorization from the client or court subpoena.

KEY CONCEPTS

image A dental hygiene care plan is an evidence-based, client-centered written proposal to meet the unmet human needs of a client that are related to oral health and within the scope of dental hygiene practice.
image The dental hygiene diagnosis provides the foundation for care plan development.
image The care plan reflects the dental hygiene diagnosis, client-centered goals, dental hygiene interventions, detailed appointment schedule, and expected outcomes.
image A well-formulated and executed care plan will increase the likelihood of a positive outcome in the dental hygiene care process.
image Evaluation is a critical component of the dental hygiene process and a necessary step to document evidence of care plan success in achieving a desired outcome in the client’s oral health status.
image Documentation of the dental hygiene process of care in the client’s record is a management strategy to minimize the risk of litigation.
image Without evaluation, a dental hygienist’s contribution to the oral health of the client is invisible and undervalued.

CRITICAL THINKING EXERCISES

Client Profile 1: James W., a 50-year-old man, is a long-haul truck driver who is taking hydrochlorothiazide for hypertension, drinks two to three cups of coffee per day, and smokes one pack of cigarettes per day.

Dental History: James’ last dental appointment was 1 month ago for extraction of tooth 2, which was periodontally involved; before this time, 10 years had passed since his last dental appointment. He brushes once daily with fluoride toothpaste, and his chief complaint is that “I have pain in the upper left molar region, and I do not want to lose any more teeth.”

Assessment: Clinical examination reveals nicotine stomatitis, Class II malocclusion with a moderate overbite, and a coated tongue. Dental examination reveals missing third molars and maxillary right second molar; generalized moderate brown stain; slight subgingival calculus; localized moderate supragingival calculus in sextant 5; and Class I and II amalgam restorations.

Gingival and periodontal assessment findings reveal generalized moderate marginal inflammation, generalized slight recession; localized moderate recession on facial surfaces of sextants 3 and 4; bleeding on probing; pocket depths of 3 to 5 mm, with attachment loss at 4 to 5 mm; Class II and III furcations and Class I mobility on teeth No. 14 and No. 15. Full-mouth periapical and vertical bitewing radiographs show evidence of a recurrent carious lesion on tooth 30 and root caries on the distal surface of tooth 14, generalized moderate horizontal bone loss in molar regions, and localized vertical bone loss on the distal surface of tooth 14.

1. Formulate a dental hygiene care plan for this client.
2. Refer to Table 20-1 and identify the phase of care that is being planned and implemented for this client.
3. Discuss the client’s likely prognosis after implementation of the dental hygiene care plan.

Client Profile 2: Mrs. Wilton is a 57-year-old woman who has been married for 35 years. She cares for her two grandchildren, Dayne, age 2, and Katie, age 4, 3 days per week while the children’s mother works.

Health History: Mrs. Wilton has type 2 diabetes, controlled by oral hypoglycemic medication and diet, and hypertension, controlled by Avapro. She sees her physician on a regular basis for her diabetes and hypertension.

Dental History: Mrs. Wilton has not seen a dentist in 7 years. She is a client of record at the local University dental hygiene clinic where she has been treated every 4 to 6 months for the past 4 years because she does not have dental insurance. At each past continued-care appointment, she has had generalized type 2 I chronic periodontal disease. Each past care plan has indicated the dental hygiene diagnosis “Human need for skin and mucous membrane integrity of the head and neck due to inadequate oral biofilm management by the client and generalized moderate to heavy calculus as evidenced by generalized bleeding on probing.” The care plans have emphasized the same intervention strategies, i.e., modified Bass toothbrushing and flossing followed by a series of quadrant root debridement appointments. Appointment notes indicate that the client keeps her scheduled appointments and properly demonstrates recommended toothbrushing and flossing skills; however, she states she does not like to floss.

Supplemental Notes: Mrs. Wilton arrives today at the dental hygiene clinic for a scheduled continued-care visit. No changes have occurred in her health history; all medications are taken as prescribed; blood pressure is within normal limits. Assessment findings reveal no change in oral health status since the last continued-care appointment. Reason for her visit: “to have my teeth cleaned.”

1. Considering the dental hygiene process of care, what legal and ethical issues are present?
2. Discuss possible factors influencing why the client’s oral health has not improved from recare to next recare.
3. Suggest alternative dental hygiene diagnoses and formulate a dental hygiene care plan.
4. Role-play a clinician’s presentation of the care plan to the client for informed consent.
5. Write progress notes for this scenario that document evidence of the dental hygiene process of care including assessment, diagnosis, and care plan presentation for informed consent.

Refer to the Procedures Manual where rationales are provided for the steps outlined in the procedures presented in this chapter.

REFERENCES

1. Darby M, Walsh M : A pplication of the human needs conceptual model to dental hygiene practice. Presented at the 14th International Symposium on Dental Hygiene, Florence, Italy, July 1998 .

2. Vaughn L. Common areas of legal risk. Access. 2007;21:37.

3. Vaughn L. Common areas of legal risk. Access. 2007;21:49.

Visit the image website at http://evolve.elsevier.com/Darby/Hygiene for competency forms, suggested readings, glossary, and related websites..