I work in a busy, one-doctor practice with two other hygienists. Our schedule is booked very tightly, and it is not uncommon for us to run behind schedule. We get 40 minutes for the average prophy patient and one hour for periodontal patients.
I know periodontal probing is important, but it is very difficult to work periodontal probing into a 40-minute appointment. Most of the time, I check a few marked areas and write "WNL" (within normal limits) in the chart. However, to do a full periodontal probing and record all the numbers is time-consuming. I really only have time to do that when I have a periodontal patient.
My question is this: Are my chart notations sufficient? What is the standard of care related to probing and recording of probe readings?
I think you already know the answer to your question. That's why you are "feeling worried."
The standard of care is generally defined as the level of care provided by the majority of practitioners in the same field. However, we must also consider the concept of "prudent practice," which includes "methods taught in dental/dental hygiene schools, continuing-education courses, and/or covered in articles" (Hodges, 1998). Courts have been known to hold practitioners to the same standards as specialists when patients have not been referred.
Certainly, the periodontal charting is an important part of diagnosis of periodontal disease. However, many hygienists think of periodontal charting as a burdensome part of their average day and find it easy to omit. Hodges (1998), quoting McCullough, relates a study published in the Journal of Periodontology that "showed that out of 2,488 records chosen at random in 36 dental practices, only 16 percent were complete or adequate in regard to periodontal information" (p. 524). In my chart audits in dental practices, I have observed a similar situation. In one recent practice, out of 30 adult charts I pulled at random from the patient files, only two had an up-to-date periodontal charting.
Failure to diagnose periodontal disease is one of the top reasons dentists are sued for malpractice. Since most dentists depend on their hygienists to be vigilant with regard to periodontal charting and apprise them of any pocketing that is discovered, it is the hygienist's responsibility to ensure timely chartings are performed and recorded. It is a serious matter.
According to Frank DeLuca, DDS, JD, the standard of care in dentistry for periodontal charting is a full mouth, six-point probing with ALL numbers recorded at a minimum of once per year for all adult patients. The reason he recommends recording all numbers is that if a jury of nondental individuals examines a periodontal chart that only has a few scattered numbers, it appears (to them) as an incomplete chart. Remember, in the eyes of the law, if it's not written in the chart, it never happened.
Some people ask me about using the PSR measure in lieu of a full-mouth charting. What does "PSR" mean? It means "Periodontal Screening and Recording." We used PSR when I taught dental hygiene as a screening tool to help us determine if new patients to our clinic should be placed with a freshman or senior student. It is a screening device, not a full-mouth charting. PSR is not to be used instead of a full-mouth charting, because PSR is an incomplete charting at best.
You mentioned writing "WNL" in the chart. This made me chuckle, as my good friend, Patti DiGangi, RDH, BS, says this really means "we never looked." Believe me, I am sympathetic to your dilemma, because I know what it is like to work in a hectic, time-pressed environment. If I had to cut corners on anything to get back on schedule, it would usually be the periodontal charting. For me to chart solo and write all the numbers down would take at least 10 minutes and possibly longer with some patients.
However, with an assistant by my side recording numbers in the computer or on the patient chart, I could do a complete full-mouth, six-point probing in about three minutes. That's a big time difference when you multiply that times 10 patients.
The answer to your problem is to have people to assist with recording the probe readings as you call them out. Sometimes the doctor will have to say to the other staff members, "I need everyone"s help regarding periodontal charting. The hygienists can perform this task efficiently if they have someone to record the numbers. Therefore, I"d like to ask each of you to help when you can. Not having an up-to-date charting puts us in a potentially serious situation legally, and if I get sued, it could affect your jobs." I think this puts the situation in perspective.
Three full-time hygienists mean approximately 30 patients to check throughout the day for one doctor, which is, no doubt, a daunting task. If you currently have only one assistant, she is probably maxed out time-wise assisting the doctor. Depending on how many chairside assistants there are in the practice, this may be a good time to hire an additional assistant to help with chartings and other varied clinical duties. Some offices use business assistants as well to help record periodontal charting numbers.
Another wonderful alternative is voice-activated periodontal charting systems. PerioPal® (www.periopal.com) comes to mind. This system allows the hygienist to speak the probing values while probing, and they are recorded digitally.
Another suggestion for you is to be proactive in scheduling, which means when you know your patient will be due for a full-mouth probing on the next visit, allow more time in the schedule for that to happen. An extra 10 minutes can make all the difference in whether the probing is done or not. I agree that 40 minutes is insufficient time for performing all the assessments that are vitally important in providing competent care and providing a thorough prophylaxis.
An important side benefit of full probing on a regular basis is that you will discover more periodontal disease. Nonsurgical treatment of periodontal disease is the most productive procedure a hygienist performs. So, it follows that your production will increase as you detect periodontal disease and schedule treatment. You cannot treat it until it is diagnosed, and periodontal probing is the way it is detected.
It is important to communicate your concerns to the doctor. When he or she understands the implications of your dilemma, the solution will be evident. You need a little extra time and someone to help record readings, or purchase a voice-activated system.
About the Author
Dianne Glasscoe-Watterson, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or e-mail [email protected]. Visit her Web site at www.professionaldentalmgmt.com.
Hodges, Kathleen. (1998). Concepts in Nonsurgical Periodontal Therapy. Albany, NY: Delmar Publishing.