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Inventory

Describe system of monitoring inventory


A.6 PRIVILEGING/CREDENTIALING
PURPOSE

The primary purpose of this process is to ensure that only practitioners who are qualified and competent to practice are delivering services to patients.  The process not only helps to enhance patient safety, but it also helps to protect the health care organization from liability. Credentialing is the process of documenting the licensure, professional education and training, experience, current competence, and health status of a practitioner.  Privileging is establishing the manner in which a practitioner is allowed to practice (i.e., the scope of practice and types of procedures carried out by the medical practitioner).

PROCEDURE

[Facility] Dental Program will follow Medical/Dental Staff Bylaws or other guidance established by the Facility’s Governing Body. Copies are on file [location].

Dental Privileges Request Forms and Application for Appointment to the Medical Staff are completed by each dentist, [and hygienist if Bylaws specify dental hygienists as providers] and a copy kept in [location].

All visiting and temporary staff will follow the guidelines outlined in the Medical Dental Staff Bylaws or other guidance established by the Governing Body. Credentials will be checked prior to any providers’ delivery of services. All non licensed staff will be assigned to a mentor for direction and oversight.
Each dental program should use a Core Dental Privileging Request Form. Dentists [and hygienists if appropriate] requesting privileges for clinical services must specify categories for which privileges are requested. Full or limited privileges will be granted or denied on the basis of the requesting the provider’s documented training and experience. Documentation of licensure, training and experience in the form of an appropriate training certificate or a letter specifying past experience from the requesting dental provider’s current or immediate past dental supervisor must accompany the Dental Privileges Request Form. [Insert Privileging Application form]

A.7 DOCUMENTATION

PURPOSE


To ensure adequate record keeping for all services provided by the dental clinic.

PROCEDURE



Dental Record

The dental record may be maintained in a hard copy (paper chart) or in an electronic dental record. Regardless of format, the minimal requirements of the dental record are:



  1. Medical history

  2. Pain documentation

  3. Progress notes including all clinical impressions, treatments, medications, procedure codes, and next visit needs

  4. Examination and treatment plan form (for comprehensive care)

  5. SOAP format (required for Emergency Care)

  6. Consultations and referrals if needed

  7. Laboratory prescriptions and results if needed

  8. Radiographs and documentation that x-rays were read

  9. Provider’s signature with credentials (may be an electronic signature for EDR)

Documentation

At every dental visit the dental provider will update and sign or initial the medical history. Medical history update may be done on the medical history form or in the progress note. All dental services will be documented in ink, contain the date and services provided, and contain the provider’s signature with credentials. Precautions needed for specific physical status will be noted as needed (e.g. appropriate premedication, laboratory test results, or blood pressure recorded for patients with a history of hypertension)

Informed consent will be obtained for all routine services. See “Informed Consent” Policy B.13 for a full description of informed consent procedures.




    Pain Assessment and Documentation

    Progress notes will indicate the patient’s pain (0-10 scale) at each dental appointment. See Policy A.7 for complete pain assessment and documentation.







Emergency Visits

The dentist will use the S.O.A.P. format for all emergency visits.



  1. SUBJECTIVE S COMPLAINT, PATEINT’S REPORT OF SYMPTOMS

  2. OBJECTIVE O OBSERVATION OF PROBLEM, RESULTS OF DIAGNOSTIC TESTS

  3. ASSESSMENT A DIAGNOSIS

  4. PLAN P TREATMENT PROVIDED



    Routine Care

    A comprehensive examination form will be completed at the initial dental exam, in the event of significant medical or dental changes, or at least every 3 years. The examination form will contain a record of findings in the oral cavity for hard and soft tissues, periodontal screening, temporomandibular joint health, orthodontic status, and documentation that radiographs have been read by the dentist, and radiographic results. A treatment plan based on the results of the examination will be completed. Updates or changes to the treatment plan will be dated and initialed by the dentist as needed. Upon completion of the examination form, the dental provider will explain the findings of the exam to the patient or parent/guardian and obtain informed consent for the proposed treatment plan.



A.8 PAIN DOCUMENTATION
PURPOSE

To establish consistent procedures for assessing and documenting patient’s pain, using an age appropriate assessment tool.


PROCEDURE

    Progress notes will indicate the patient’s pain (0-10 scale) at each dental appointment. If pain is indicated, progress notes will include a description of pain intensity and quality (e.g. location, duration, exacerbating or relieving factors) and management strategies. (See Attached Adult and Pediatric Pain Scale Assessment tools)

    If a patient’s pain cannot be adequately managed by the treating dentist, the patient will be referred for appropriate assessment and treatment. (See Pain Management Policy #B.16)


Adult Pain Assessment Scale



































0

1

2

3

4

5

6

7

8

9

10

No

Pain





Mild

Pain





Moderate

Pain





Severe

Pain





Very

Severe


Pain




Worst

Possible


Pain


Pain Assessment Scale Key:
0 = No Pain

1-3 = Mild Pain – MILD PAIN ANNOYING – pain is present but does not limit activity

4-5 = Moderate PainNAGGING PAIN, UNCOMFORTABLE, TROUBLESOME – can do most activities with rest periods

6-7 = Severe PainMISERABLE, DISTRESSING – unable to do some activities because of pain

8-9 = Very Severe Pain – INTENSE, DREADFUL, HORRIBLE – unable to do most activities because of pain

10 = Worst Possible Pain WORST PAIN POSSIBLE, UNBEARABLE – unable to do any activities because of pain

Pediatric Pain Assessment Scale







































0

1

2

3

4

5

6

7

8

9

10

No Hurt




Hurts

Little


Bit




Hurts

Little


More




Hurts

Even


More




Hurts

Whole


Lot




Hurts

Worst



Pain Assessment Scale Key:
0 = No Hurt

1-3 = Hurts Little Bit – MILD PAIN ANNOYING – pain is present but does not limit activity

4-5 = Hurts Little More – NAGGING PAIN, UNCOMFORTABLE, TROUBLESOME – can do most activities with rest periods

6-7 = Hurts Even More – MISERABLE, DISTRESSING – unable to do some activities because of pain

8-9 = Hurts Whole Lot – INTENSE, DREADFUL, HORRIBLE – unable to do most activities because of pain

10 = Hurts Worst – WORST PAIN POSSIBLE, UNBEARABLE – unable to do any activities because of pain




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