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:

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 andwith patient consent, allied health care providers are consulted to establish the appropriateness and thesafety 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:

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:

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:

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

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:

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:

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

 11th May

A complete book list will be provided during Orientation and available on Blackboard