Guidance to Conducting an Oral Assessment

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Guidance to Conducting an Oral Assessment
The following guidance is provided to clarify expectations for conducting an oral assessment. Refer to ER # 2.03900 on the web for complete policy guidance. Contact your assigned technical assistance nutritionist with questions.
Oral Assessment – Screening for problems of the mouth, teeth and gums. The oral assessment may be an oral inspection (most common with infants) or it may be completed by asking the Mandatory Dental Health Questions (MDHQs).

Oral InspectionA visual check of the mouth, teeth and gums performed by qualified staff.

Mandatory Dental Health Questions (MDHQs) – A set of questions determined by Missouri WIC to meet the requirements of an oral assessment. These questions must be asked by qualified staff if the oral inspection is not performed.
Which participants must have an oral assessment?

Every participant must have an oral assessment completed during each certification, including infants. An oral assessment is not required at the infant 6 month reassessment.

Which participants can be assigned Risk Factor 381, Dental Problems?

Risk factor 381 may be assigned to any category of participant, including infants, children, prenatals, breastfeeding, partially breastfeeding, and non-breastfeeding women.

Who may conduct the oral assessment? The oral inspection? MDHQs?

The CPA, WIC Certifier, or HPA may conduct the oral assessment, whether the assessment is completed by oral inspection or by asking the mandatory dental health questions.

What training is required to complete the oral assessment?

Staff who have completed HPA training are trained to conduct an oral assessment.

What must be documented?

According to ER # 2.03900, two items must be documented.

  1. How the oral assessment was performed (Oral inspection or mandatory dental health questions). It is acceptable to abbreviate to OI or MDHQs.

  2. The results of the oral assessment, for instance “no problems” or “unfilled cavities, avoids sweets.”

Where should this be documented?

At this time, there are four preferred locations in MOWINS for documenting the oral assessment.

  1. General notes

  2. SOAP notes

  3. VENA tab after the question “What nutrition and health questions do you have today?” This is offered as an option so that LWPs who prefer to document in the VENA tab all document consistently in the same location.

  4. The scanned Nutrition Assessment form. This will eventually not be an option, so make plans to transition to General notes, SOAP notes, or the VENA tab.

Is it OK to document the oral assessment in local use questions?

No. From experience, we have learned that there are problems with using local use questions for documentation of the oral assessment.

  • Answers documented in local use questions do not transfer with the participant who transfers to another LWP in Missouri.

  • Local agency and state staff are unable to associate the selected answers with a certification, so there is no way to know during which certification the oral assessment was completed. Drop down selections may have been selected during a previous certification.

What are other LWPs doing?

From the oral assessment survey conducted in March 2011, we’ve learned more about how Missouri agencies conduct and document the oral assessment. 106 LWPs responded to the survey, 23 did not respond. 10 LWPs sent in two completed surveys. The results of the survey are summarized in the attached power point presentation.

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