2009 OHP Dental Record Review

In 2009, ODS completed a dental record review as part of our dental quality improvement efforts and our commitment to ensure safe and effective care for our members.

About the review

We reviewed 525 OHP members’ records. The review focused on the documentation of 14 elements, and the findings were used to monitor and evaluate whether the services delivered in the provider’s office followed guidelines set forth by the Oregon Dental Practice Act. These elements include, but are not limited to, patient information and health history, extensive examination, oral hygiene instruction, treatment plans, progress notes, diagnostics and consent. The ODS documentation goal is 80 percent for each element.

The members selected for this review included:

  • 49 children under two years old
  • 211 children from two to five years old
  • 265 pregnant women

Results: high level of member care

In 2009, aggregate scores met or exceeded the goal in the following areas:

  • Patient information and health history, oral examination and treatment plans
  • Progress notes legibility, date and description of services, and notes signed and dated
  • Diagnostics noted and documentation of signed consent forms

Results: areas for improvement

The ODS Dental Quality Improvement Committee (DQIC), which includes community-based dentists, analyzed the results of the review for provider educational opportunities. The ODS DQIC encourages dentists to note the documentation rates for the four areas below. Each showed an aggregate score of less than 80 percent and represent improvement opportunities to ensure safe and effective care:

Periodontal charting 49%
Documentation of anesthesia/analgesia 52%

Oral hygiene instruction

59%

Documentation of asking whether patients use tobacco

68%

Results: improved tobacco cessation efforts

The review showed that 68 percent of dental history forms ask whether or not a patient uses tobacco. This improved by 6 percentage points from the 2007 record review. There was marked improvement in the tobacco cessation efforts for patients who indicated they used tobacco. Fourteen percent of those who answered yes were advised to quit and 7 percent were referred for assistance with quitting. In 2007, documentation showed that less than 1 percent were advised or assisted with a referral to get help with tobacco cessation.

You are welcome to use the patient information form that is available on the Dentists Benefits Insurance Company’s website. You can find it under the risk management tab or directly at www.dentistsbenefits.com/docs/patient_hist.pdf. The form asks whether or not the patient uses tobacco. In addition, the updated 2010 OHP Dental Provider Handbook has information about how you can help your patients with tobacco cessation. The updated handbook is available on the ODS website at http://www.odscompanies.com/pdfs/Dentist_Handbook_OHP.pdf.

For more information

Thank you for your participation in the 2009 dental record review. Your partnership with ODS shows continuing commitment to promote safe and effective care to our members.

If you have any questions, please contact Charlene Yoder, ODS Quality Improvement Specialist, at 800-852-5195 ext. 5678.

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