Documenting with Clarity, Compliance, and Confidence

Accurate and comprehensive documentation is essential for safe, ethical, and client-centred care. This course provides dental hygienists with practical tools and strategies to meet the CDHO’s record-keeping standards outlined in the Records Regulations while improving efficiency in daily practice. Together, we will create a reproducible reference framework to help you achieve detailed and precise documentation that supports clinical decision-making and reinforces professional accountability. Participants will also receive a downloadable reference guide featuring standardized abbreviations and commonly used indices to streamline their documentation process.

• Apply a standardized approach to documenting assessments, informed consent, client self-care goals, and post-care instructions.

• Construct accurate dental hygiene diagnosis and care plan statements with measurable goals and expected outcomes.

• Use a documentation framework that supports CDHO standards and enhances clinical efficiency.

• Record interdisciplinary collaboration and referrals appropriately to reflect continuity of care.