Course Title: Examine, record and assess patient histories and dental records to formulate a dental hygiene

National Element Code & Title:

TAFEDH005 Examine, record and assess patient histories and dental records to formulate a dental hygiene

Performance Criteria:

1.1 Create a non-threatening and professional environment
through the use of inclusive verbal dialogue and
appropriate body language gestures
1.2 Communicate with patient to promote informative
dialogue that is tailored to the patient’s level of
comprehension
1.3 Ascertain chief complaint, medical, dental and social
history information
1.4 Accuracy of information is established through peer and
clinic patient verification
1.5 Organise the use of an interpreting service if a need is
established

Performance Criteria:

2.1 Utilise both written and electronic forms of recording
client data
2.2 Record relevant data to accurately reflect patient’s past
and current social, dental and medical status
2.3 Complete patient nutritional assessment to provide
analysis against Australian Dietary guidelines
2.4 Data is recorded according to a standard code of
professional practice using correct terminology
2.5 Patient and/or/carers/guardians are guided to complete
data forms as required
2.6 Patient and/or/carers/guardians verification is obtained
to confirm accuracy of data, where appropriate

Performance Criteria:

3.1 Patient’s social, dental and medical histories are
assessed in accordance with relevant guidelines and
legislative requirements
3.2 Relevant issues requiring individualised oral health care
are identified, interpreted and prioritised
3.3 Risk factors affecting the presence of disease and
outcome of treatment are identified and interpreted
3.3 Areas that need to be bought to the attention of the
dentist and/or other health professionals are brought to
the attention of the clinical supervisor to avoid medical or dental emergencies
3.4 Assessment procedures are conducted within legislative
requirements and are within the current standards of
dental hygiene practice and care as set by the relevant
guidelines

Performance Criteria:

4.1 Utilise both written and electronic forms of recording
client data
4.2 Relevant data is recorded to accurately reflect patient’s
extra oral and intra oral health status
4.3 Data is recorded according to a standard code of
professional practice using correct terminology
4.4 Data on initial examination is collected in a format that
will serve as baseline data to assist with the monitoring
of future treatment and maintenance outcomes

Performance Criteria:

5.1 Patient is kept informed on the procedure and the
rationale of the process of conducting an examination.
Consent to undertake the examination procedure is
confirmed with the patient
5.2 Facial and oral tissues are examined and recorded
accurately
5.3 All documented information is considered as baseline
data for future treatment outcomes and for long term
monitoring of oral health
5.4 Examination procedures are carried out according to
occupational health, safety and welfare guidelines and
current Infection control policy and procedures

Performance Criteria:

6.1 Clinical findings are interpreted and assessed in
accordance with the current standards of dental hygiene
practice and care as set by the relevant guidelines and
legislative requirements
6.2 A thorough periodontal, hard and soft oral tissue health
assessment is completed
6.3 Localised risk factors contributing to oral disease are
identified and assessed
6.4 Oral health issues requiring individualised hygiene
treatment and care are identified and interpreted
6.5 A risk assessment for dental disease is completed
based on clinical evidence and current standards of
practice
6.6 Areas that need to be bought to the attention of the dentist and/or other health professionals are clearly
recognised and carried through

Performance Criteria:

7.1 Dental hygiene treatment requirements are determined
and selected based on interpretation and evaluation of
clinical findings and radiographic evidence
7.2 Hygiene treatment needs are prioritised to provide
positive treatment options that are patient focussed and
aimed at controlling and preventing the presence of
disease
7.3 The dental hygiene treatment plan is formulated as an
integral part of the patient’s overall dental treatment
plan, taking into account all systemic and local risk
factors as well as any social determinants influencing
their oral health status to provide optimum oral health
care
7.4 A customised self care program is designed as an
integral part of dental hygiene care and strategies are
devised that will provide ongoing assessment and
review, including referral if appropriate
7.5 When a need is indicated, on the dentist’s approval and
with patient consent, allied health care providers are
consulted to establish the appropriateness and the
safety of any recommended treatment options
7.6 The dental hygiene treatment plan is formulated in
accordance with legislative requirements
7.7 The dental hygiene treatment plan is discussed with the
dentist and approval is confirmed and patient consent is
obtained

Performance Criteria:

8.1 Confidentiality and the privacy of the patient is
preserved at all times
8.2 Information is obtained from relevant sources as
required based on patient consent
8.3 Significant and relevant information is imparted to other
general and oral health team members as required to
preserve the patient’s interests and safety

Nield-Gehrig Foundations of Periodontics for the Dental Hygienist 
Wilkins Clinical Practice of the Dental Hygienist
Nield-Gehrig Fundamentals of Periodontal Instrumentation