Performance Improvement Criteria

Introduction

Evaluation criteria for comprehensive pediatric dental care for children should insure that the child's needs remain foremost and that these needs are not sacrificed to the system in which the care is delivered.� With these ideas in mind, a system evaluating the completeness of treatment based upon the needs presented by the child has been developed.� These criteria have been developed as a means to evaluate whether the individual dentist, clinic or institution has met its professional responsibility to the child for whom care is being provided.�

Medical Record Documentation

Each Service is required to prepare a plan that will continually improve their medical/dental record documentation.� Results will be monitored through the quality assurance improvement process.

Why is Documentation Important?

It is universally recognized that the fundamental reason to maintain an adequate medical/dental record is its contribution to the high quality of patient care. The medical/dental record chronologically documents the care of the patient in order to:

• Enable physicians, dentists, and other health care professionals to plan and evaluate the patient�s treatment;
• Enhance communications and promote continuity of care among physicians, dentists, and other health care professionals involved in the patients care;
• Facilitate claims review and payment;
• Assist in utilization review and quality of care evaluations;
• Reduce complication related to quality improvement review;
• Provide clinical data for research and education;
• Serve as a legal document to verify the care provided (e.g. in defense of an alleged professional liability claim).

Principals of Documentation

• The medical/dental record should be complete and legible.
• The documentation of each patient encounter should include: the date; the reason for the encounter; appropriate history and physical exam; review of laboratory, radiographic data, and other ancillary services, where appropriate; assessment; and plan for care (including discharge plan, if appropriate).
• Past and present diagnoses should be accessible to the treating and/or consulting physician or dentist.
• The reasons for and results of radiographs, lab tests, and other ancillary services should be documented or included in the medical/dental record.
• Relevant health risk factors should be identified
• The patient�s progress, including response to treatment, change in treatment, in diagnosis, and patient non-compliance, should be documented
• The written plan for care should include, when appropriate; treatments and medications, specifying frequency and dosage; any referrals and consultations; patient/family education; and specific instructions for follow-up.
• The documentation should support the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of medical/dental decision making
• All entries to the medical/dental record should be dated and authenticated
• The CPT/ICD-9 ADA or Medicaid codes reported on the health insurance claim for or billing statement should reflect the documentation in the medical/dental record.

Patient Record

The importance of the record is based upon professional, ethical and legal responsibilities inherent in patient care activities.� The dental record should provide an accurate picture of the patient's status and conditions present upon entering the system, a plan whereby needs will be met, and an ongoing description of progress with the outcome ultimately justifying the care provided, or with adequate explanation as to why it did not.� All entries in the patient's record must be accurate and legible, and should be signed by or otherwise attributable to the treating clinician.

INDICATIONS: Each patient who has been examined or treated shall have an appropriate patient record.

Outcome Indicators

Expected/Desirable:

• All appropriate entries made in patient's record in black or blue ink.
• All entries complete, clear, and legible
• All entries signed by, or otherwise attributable to treating clinician and by supervising faculty if clinician is a student.
• At time of final disposition of patient, all designated needs addressed and plans for future care documented.

Unexpected/Undesirable:

• Entries into patient's record incomplete, inappropriate, unclear, or illegible.
• Signatures, or other clinician identifiers, not present where indicated.
• At final disposition, not documented how all stated needs have been addressed.

Informed Consent

Each patient (parent or legal guardian) either verbally or in written form, and documented in each patient's record shall be provided with the essential elements of informed consent within the laws of the state of New York.� Such consent shall be obtained by a licensed practitioner or a designated student and co-signed by supervising faculty.� If a standard consent form is used, a note that such form was reviewed and signed by the patient/parent should be made in the progress notes.

Informed consent shall include:

Diagnostic Procedures

1. The diagnosis, proposed therapy, any reasonable alternative therapy and the prognosis with or without the proposed therapy.
2. An explanation of any treatment or procedure about which a reasonable patient (parent) might be concerned.
3. Any reasonably foreseeable inherent risks associated with treatment, including potential failure of proposed treatment.
4. Recommendations for treatment to be performed by other dentists or physicians.�

Indications: Informed consent shall be documented for all patients for whom any treatment is to be provided.

Outcome Indicators

Expected/Desirable:

• appropriate informed consent obtained by treating practitioner, or by a designated student and cosigned by supervising faculty, documented in patient's record.

Unexpected/Undesirable:

• Informed consent not documented in patient's record.
• Consent not obtained according to state laws.
• Consent obtained too general in nature and did not specify all planned treatment, risks and alternatives.
  

Establishing a Database: Patient Examination

A data base should be assembled prior to initiating treatment.� This will include medical, dental, and family histories, as well as clinical assessment hard and soft tissues, oral hygiene, occlusion, and behavior. �Patient health history form questions should be worded so that a response is required leaving no blank spaces.� A specific area or separate form should be provided for periodic updating.� Health history forms should be signed and dated by both patient (parent) and reviewing dentist.� Medical conditions requiring special attention (e.g. patient allergies, critical diseases, etc.) shall be flagged in some systematic manner.� Laboratory studies indicated by history and examination shall be documented as part of the data base, as shall all consultations (written and verbal-telephone) with other providers, e.g., the patient's physician or other dental specialists.��������

Indications: A data base shall be established for all patients of whom any treatment is indicated.

Outcome Indicators

Expected/Desirable:

• Histories and assessments completed and recorded and of sufficient quality that accurate identification, diagnosis, and method of treatment could be assigned to each problem presented by the patient.
• High risk patients, such as those with medical problems, allergies, and those requiring chemoprophylaxis, clearly and prominently identified.

Unexpected/Undesirable

• Inadequacies present in completeness or comprehensiveness of collected data base such that appropriate treatment plan cannot be designed to meet child's needs.
• High risk patient not clearly and prominently identified.

Radiographic Evaluation

A comprehensive oral evaluation will, in most cases, include intraoral and/or extraoral radiographs, as indicated by history and clinical examination.� All radiographs made for a patient shall be recorded in the patient's record and filed with the patient's record.� The interpretation of the radiographic findings shall be documented in the patient's record.� All intraoral radiographs should be mounted sequentially for proper viewing and interpretation.� All radiographs shall be identified with other patient's name and the date they were made.

Indications: Dental intraoral and extraoral radiographs shall be made as indicated by history and clinical examinations.� The Guidelines of the United States Department of Health and Human Services Publication No.: FDA 888273; Dental Radiographic Examination, October 1987, shall be used as a guide for appropriateness.

Outcome Indicators

Expected/Desirable

• All dental radiographs made appropriately, in accordance with the United States Department of Health and Human Services Guidelines.
• All radiographs documented in patient's record and findings and/or interpretation of such radiographs reported.
• All intraoral radiographs mounted sequentially, identified and dated and all other radiographs identified and dated.

Unexpected/Undesirable

• All radiographs made not recorded.
• Radiographs inappropriate (did not follow A.A.P.D. Guidelines).
• Radiographic findings and/or interpretation not documented for all radiographs made.
• Intraoral radiographs not sequentially mounted, identified, and/or dated.

Diagnosis and Treatment Plan Formulation

A diagnosis generally implies that a disease entity or problem has been identified and assumes that a disease process can be related to the present disease state or problem.� Diagnoses should be made from the data base that has been previously collected and recorded.� A treatment plan formulated from distillation of the information gathered in the data base leading to an accurate diagnosis or determination of the patient's problems will present an effective means of dealing with the patient's needs.� The plan should include consideration of the patient's, and in the case of a child, the and parent's, statement of needs and shall be drawn directly from the recorded data base.� The treatment plan shall prioritize the patient's needs and outline methods of treatment. �Treatment plans prepared by unlicensed students shall be cosigned by supervising faculty.

Outcome Indicators

Expected/Desirable:

• Accurate diagnosis of disease present and indication of its etiology made and documented such that appropriate plan for clinical management can be developed.
• Treatment plan addresses needs and priorities of patient and/or parent and clinician.
  

Unexpected/Undesirable

• Incorrect or incomplete diagnosis made and/or subsequent plans for clinical management inappropriate or incomplete.
• Patient's and parent's needs and priorities not considered in light of disease state presented.

Delivery of Dental Care: Preventative Therapy

The need for and design of a program of preventive therapy should be documented for each patient.� A preventive program should include the following basic modes of therapy as each patient's needs dictate.

1. �Knowledge regarding etiology of dental diseases
2. Oral hygiene Instruction
3. Dietary assessments and counseling
4. Appropriate fluoride therapies
5. Occlusal sealants
6. Preventive recall program

Indications: Each patient who is being treated comprehensively shall have a preventive therapy and recall plan documented.

Outcome Indicators

Expected/Desirable:

• Patient's needs accurately assessed and documented.
• Preventive plan presented which utilizes currently available therapies to eliminate, reduce and/or prevent recurrence of dental/oral diseases
• Follow-up preventive recall program documented.

Unexpected/Undesirable

• Patient's preventive needs not documented.
• Preventive plan not representative of realistic means for reduction of patient's oral disease process.
• Established goals for disease reduction not met.
• Follow-up preventive recall program not documented.

Delivery of Dental Care: Behavoir Management

The ability of the clinician to manage the fears and anxieties of the patient is an integral aspect of dental practice especially pediatric dentistry.� The necessary skills involve the identification of the type of behavior presented in the dental situation and institution of a strategy to effectively deal with that behavior.� Although modification of the patient's behavior may not be identified as a separate entity in the patient's treatment plan, an initial assessment, as well as progress in this area, should be recorded in the progress notes.� The use of specific behavior management techniques with children, especially aversive techniques, sedation and general anesthesia, must be identified along with the length of time they were employed.� Inhalation sedation and general anesthesia shall be documented by identifying the agent(s) utilized, their concentration and the time employed.� Enteral and parenteral drugs shall be identified by agent and dose in milligrams.� Parenteral drugs shall be documented by time and site of administration.� The effectiveness of any technique employed shall be documented.

Indications: Each patient for whom any service or treatment is provided shall have documented his or her initial behavior.� If behavior is inappropriate or uncooperative, the effectiveness of any technique employed to deal with such behavior shall also be documented.

Outcome Indicators

Expected/Desirable:

• Patient's behavior assessed at onset of treatment and during� treatment sequence, and appropriately recorded in progress notes.
• Specific management techniques and their indication documented along with their effectiveness.
• Sedative and anesthetic drugs documented by name, route, time, and site of administration, dose in milligrams, effectiveness and patient response.
• During course of treatment, it should be documented that child developed acceptable behavior or exhibited behavior appropriate for developmental level and comprehension skills.

Unexpected/Undesirable

• Initial assessment of child's behavior not recorded.
• Specific management techniques, their indication, and effectiveness not documented.
• Sedative and/or anesthetic drugs not documented by name, time, and route of administration, dose in milligrams and effectiveness.
• During course of treatment, not documented that child developed acceptable behavior or behavior appropriate for developmental level and comprehensive skills.

Delivery of Dental Care: Growth Assessment and Supervision and Evaluation Guidance of the Devloping Occlusion

A thorough diagnosis of the child's needs based on the gathering of subjective and objective data must be completed prior to establishing treatment goals in this area.� Appropriate data may include, but not necessarily be limited to, the following:

1. Study models, appropriately identified, dated, and trimmed in registered occlusion;
2. Appropriate model and/or space analysis;
3. Intraoral radiographs, appropriately mounted, identified and dated;
4. Cephalometric radiographs and analysis appropriately identified and dated;
5. Appropriate intra- and extra-oral photographs and/or slides;
6. Appropriate consultation with other specialists.

The treatment goals shall be clearly stated and responsibilities for accomplishing those goals assigned.� Progress shall be documented and re-evaluation performed as necessary throughout treatment.� Interprofessional consultation and/or referral for evaluation or treatment shall be documented.

Indications: Any patient for whom the need for growth guidance or treatment of the developing occlusion has been established shall have the diagnoses, any proposed treatment plan, and all treatment provided documented.� Any treatment found necessary by the examining clinician which is deemed to be beyond the clinician's training, knowledge or experience, shall be referred for further evaluation and/or treatment and such referral shall be documented.

Outcome Indicators

Expected/Desirable

• Data collected and diagnosis made relative to growth guidance and/or developing occlusion problems
• Realistic treatment goals established and documented.
• Treatment either completed or in progress and appropriate documentation evident in patient's record.
• Documentation of referral for necessary treatment not provided by examining clinician.

Unexpected/Undesirable

• Incomplete data base used for making treatment decisions.
• Treatment goals not documented.
• Treatment follow-up not documented or documentation inadequate.
• Referrals inappropriate
• Referrals not documented.

Delivery of Dental Care Restorative Treatment

Restorative treatment shall be carried out in a judicious manner according to the established treatment plan.� The overall quality of care delivered shall be such that the disease or condition has been eliminated; anatomical form, function and esthetic integrity is restored; and the restoration has not caused iatrogenic disease.

Indications: Any patient for whom restorative treatment is planned and/or provided shall have such plan and treatment documented.

Outcome Indicators

Expected/Desirable

• All restorative treatment completed according to treatment plan or modifications noted and appropriately documented in patient's record.
• Local anesthesia and other drugs or medications administered during treatment process identified and dose recorded in milligrams or other appropriate units.

Unexpected/Undesirable

• Restorations not noted or not completed according to treatment plan and/or modifications not appropriately documented.
• Anesthetics and other drugs or medications administered not identified and dose not recorded in milligrams or other appropriate units.

Delivery of Care: Soft Tissue Treatment or Surgical Services

Soft tissue treatment and/or surgical services, including gingival, periodontal and or surgical procedures and extractions shall be carried out according to the treatment plan and appropriately documented in the patient's record along with appropriate radiographs necessary to document the presence of Pathology indicating surgical treatment.

Indications: Any patient for whom soft tissue and/or surgical treatment is planned or provided shall have such plan, and subsequent treatment documented.

Outcome Indicators

Expected/Desirable:

• All soft tissue and/or surgical treatment completed according to treatment plan and appropriately documented in patients record.
• There should be no excessive blood loss, delayed healing, postoperative infection, or other complications; however, when present such outcomes shall be documented.
• Local anesthetics and other drugs or medications administered identified and dose recorded in milligrams or other appropriate units.

Unexpected/Undesirable

• Soft tissue and/or surgical treatment not completed according to treatment plan.
• Treatment or services provided not appropriately documented.
• Excessive blood loss, delayed healing, and/or post operative infection not documented.
• Local anesthetics and other drugs and medications administered not identified and/or dose not recorded in milligrams or other appropriate units.