Best Practice for Clinical Documentation

Recordkeeping is essential for providing safe, ethical, and patient-centred dental hygiene care. Guided by the Canadian Dental Hygienists’ standards of practice and provincial regulatory authorities, this 1-hour session focuses on improving documentation at all stages of the ADPIE process: Assessment, Diagnosis, Planning, Implementation, and Evaluation. Participants will explore practical tools, standardization strategies, and key legal and professional requirements to improve clarity, accuracy, and accountability in clinical records. The goal is to provide documentation to support informed decision-making, continuity of care, and professional responsibility.

• Describe recordkeeping responsibilities outlined in the Canadian Dental Hygienists’ standards of practice.

• Apply the ADPIE framework to guide consistent and complete documentation throughout client care.

• Integrate standardized strategies for documenting assessments, informed consent, goals, and outcomes to ensure consistency and accuracy.

• Enhance professional accountability by documenting client interactions accurately and in an ethical manner.