Chapter 3 – Health Care Operations

Policy

• All California Department of Corrections and Rehabilitation (CDCR) dental personnel shall use the Electronic Dental Record System (EDRS) to document all dental treatment rendered to CDCR patients, including medications utilized during dental treatment.

Purpose

• To establish procedures for the correct documentation in the EDRS of dental services rendered to patients and to provide guidelines for the development, utilization and management of health records.

Procedure

• General Health Record Organization and Maintenance

  • A health record shall be maintained for each patient consistent with applicable laws and in accordance with Division of Health Care Services (DHCS) Medical Services Standards.

  • CDCR dental personnel shall abide by EDRS Workflows and Job Aids as well as Electronic Health Record System (EHRS) Workflows in the utilization and management of patient health records. Only approved CDCR and CDC forms or forms generated by an outside dental/medical consultant, (e.g., Oral Surgeon), are to be included in the health record, (see Appendix 1 at the end).

  • When the EDRS or EHRS are not available, dental staff shall implement downtime procedures. When this occurs, all paper forms shall be filled out completely including, but not limited to, the patient demographic information block located in the lower portion of some CDCR forms or at the top of other CDCR forms. This information must be completed if any entry is made on any part of the form.

  • The health record shall contain the following:

    • Identification data.

    • Problem List (including allergies, special needs, chronic illness clinics, permanent medical passes, non-English speaking status, etc.).

    • Receiving, screening and health assessment records.

    • Prescribed medication and therapeutic orders.

    • Reports of laboratory, radiographic and diagnostic studies.

    • Clinic notes.

    • Special needs treatment plans, if any.

    • Immunization records.

    • All findings, diagnoses, treatment and dispositions.

    • Informed consent, treatment refusal and release of information forms.

    • All consultant’s reports and procedural results.

    • Discharge summaries of inpatient admissions and hospitalizations.

    • Place, date and time of each health care encounter.

    • Signature, either electronic or handwritten, and title of each documenter.

  • All verbal or telephone orders shall be signed or electronically authorized via Computerized Provider Order Entry as outlined in the Health Care Department Operations Manual, (HCDOM), Section 3.3.5.10(c)(1)(A) and (B).

  • All dental encounters and services rendered, either direct hands-on care or indirect care, (e.g., radiological interpretations, written responses to CDCR 7362s, specialty clinics, on call contacts, consultations, or discharge summaries from inpatient admissions), must be documented in the health record at the time treatment is provided or when observations are made by the appropriate health care provider.

    • Prior to seating a patient in the dental operatory, dental staff shall confirm each patient’s identity by verifying the individual’s first and last name, date of birth, and CDCR number. The patient identification process shall be documented in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

    • Prior to performing any invasive, irreversible procedure, at least two dental clinical staff (Dentist, Dental Assistant, Dental Hygienist, Oral Surgeon) shall carry out a Time Out Protocol to confirm correct patient, correct procedure and correct site. The Time Out Protocol process shall be documented in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

    • EDRS clinical notes shall be signed no later than close of business the day treatment is provided or observations are made.

  • Changes or error corrections to an existing clinical note in the EDRS shall be made by generating an addendum to the original document. For paper documents, the complete obliteration of any entry and use of correction fluid is prohibited.  Changes or error corrections shall be made by drawing a single line through the information being changed or corrected. The individual making such changes shall initial, date and note the reason for the changes.

  • All dental health care providers shall utilize the Subjective, Objective, Assessment, Plan, Education format in documenting patient care.  Entries made in a patient’s dental health record as the result of a visit for the evaluation or treatment of a specific or routine complaint must include, but are not limited to, the following:

    • Subjective – Patient’s chief complaint or purpose of visit.

    • Objective – Objective findings.

    • Assessment – Diagnosis or clinical impression.

    • Plan – Proposed treatment plan.

    • Education – Patient education.

  • Only approved CDCR forms are authorized for inclusion in the health record.  The practice of using unapproved forms or making modifications to approved forms is not authorized for permanent inclusion in the health record.  To avoid misinterpretations, only the approved list of symbols and abbreviations contained in the California Correctional Health Care Services Approved Abbreviations (MCV) shall be utilized.  This does not pertain to the filing of appropriate clinical information. 

  • Health Information Management (HIM) shall ensure that a random sampling of health care forms and documents scanned into the EDRS Document Center are reviewed as part of the quality assurance process.  In the event a health record is incomplete due to the death, resignation, termination, or incapacitation of the attending clinician, it shall be given to the unit health supervisor, or if they are the person who is no longer available, then the Chief Executive Officer or designee, or Supervising Dentist (SD) or designee at the local institution shall determine if some other provider on staff can complete the record.

• Dental Health Record Organization and Maintenance

  • The following documents are authorized for scanning into the EDRS Document Center:

    • CDCR 237-F, Dental Pain Profile.

    • CDCR 239, Prosthetic Prescription.

    • CDCR 7225-D, Dental Refusal of Examination and/or Treatment.

    • CDCR 7342, Informed Consent to Surgical, Special Diagnostic, or Therapeutic Procedures.

    • CDCR 7362, Health Care Services Request Form.

    • CDCR 7423, Notification of Reception Center Dental Screening. 

    • Dental Consent Forms

      • CDCR 7422, Informed Consent for Silver Diamine Fluoride Treatment.

      • CDCR 7424, Informed Consent for Root Canal Treatment.

      • CDCR 7425, Informed Consent for Extraction(s).

      • CDCR 7426, Informed Consent for Periodontal Treatment.

      • CDCR 7428, Full and Partial Denture Agreement.

      • CDCR 7429, Informed Consent for Dental Treatment.

    • CDCR 7441, Patient Acknowledgement of Receipt of Dental Materials Fact Sheet.

    • PIA – CCW – 006, PIA Prosthetic Prescription.

  • When documentation is completed, the treating dentist or designee shall ensure all CDCR Dental forms listed in Section (c)(2)(A) are forwarded to the Office Technician (OT), or designated dental staff, for scanning into the EDRS Document Center. After scanning has been completed, the OT, or designated dental staff, shall forward the originals to HIM in accordance with EDRS Workflow 3.10-1.

  • Proper and consistent documentation must be maintained to ensure compliance with applicable state and federal laws and regulations and DHCS, health record policy.

  • Only approved methods as described in the EDRS Workflows and Job Aids shall be used for charting diseases, abnormalities, missing teeth, existing restorations and treatment completed while incarcerated.

  • Health History Information

    • At the time of each initial or periodic comprehensive dental examination and prior to providing any dental treatment, a dentist shall review the patient’s health history information in the EHRS and interview the patient using a standardized series of questions to validate the information. 

    • Health history information shall be reviewed by each provider prior to providing dental treatment including prescribing medication. Documentation of a health history review shall be made in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

    • If in the professional opinion of the treating dentist there is a clinically significant discrepancy between the health history information the patient provides and the health history information in the EHRS, the treating dentist may place an order in the EHRS for a ‘Consult to Primary Care Provider’ to obtain clarification. This action shall be documented in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

  • Treatment Plan

    • Treatment identified by a dentist shall be entered in the EDRS odontogram, in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid.

  • Authenticating Entries

    • Dentists are authorized to authenticate any entry in the dental health record and are required to authenticate direct patient care entries, patient refusals of treatment, and rescheduling or cancellation of any encounter.

    • Registered Dental Hygienists (RDH) are permitted to authenticate all entries authorized to a dental assistant and are authorized and required to authenticate entries pertaining to any RDH duty allowed and specified within the Business and Professions Code Sections 1907 to 1913.

    • (Registered) Dental Assistants (DA) are authorized and required to authenticate entries pertaining to: the provision of preventive procedures, screening (subjective and objective findings) of patients, receiving and disposition of CDCR 7362 requests and other non-direct patient care entries.

    • Office Assistants or OTs are authorized to transcribe on the dental forms those entries not requiring clinical judgment as determined to be appropriate by the SD.  They may sign the transcribed entry, but the appropriate dental personnel (dentist, RDH, [registered] DA) must authenticate the entry.  Examples of such transcription include, but are not limited to, the following:

      • Entries pertaining to the receipt of a CDCR 7362 request.

      • Patient “no show” or “failed” appointments.

      • Issuance of toothbrush, flossers, etc.

  • Clinical Notes

    • A narrative description of all dental services and any information determined to be appropriate by dental staff shall be documented in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.  Examples of supplemental information include, but are not limited to:

      • Lab reports.

      • Recommendations.

      • Probable prognosis in doubtful or complicated cases.

      • Failure to keep an appointment.

      • Failure to follow health care provider’s instructions.

      • Refusal of recommended treatment.

      • Placement on lay-in status.

      • Appointments cancelled.

      • Treatment rendered.

      • Amount and type of anesthetic utilized.

      • Medication prescribed.

    • Dental staff shall review the EDRS Signature Manager to identify unsigned clinical notes, in accordance with EDRS Workflow 4-3 and associated Back Office as well as Front Office Job Aids.

    • In the event an unsigned clinical note cannot be signed by the treating provider due to the death, resignation, termination, incapacitation, or unavailability of the individual, the SD or dentist designee shall be authorized to sign the clinical note for administrative purposes.  The SD or dentist designee shall indicate on the clinical note the reason they are signing on behalf of the treating provider prior to signing the document.

Policy

• The California Department of Corrections and Rehabilitation (CDCR), its agents, and the Division of Health Care Services shall adhere to the requirements set forth in the California Code of Regulations, Title 15, Division 3, Chapter 2, Subchapter 2, Article 1, Section 3999.202 “Informed Consent Requirement.”

Purpose

• To set forth procedures to ensure and document that a patient’s right to informed consent is observed.

Procedure

• Patients shall provide informed consent by signing the appropriate CDCR Consent Form(s) as outlined in the Health Care Department Operations Manual (HCDOM), Section 3.3.6.1, Health Records Organization and Maintenance, prior to receiving any procedure. (Reference the HCDOM, Section 3.3.5.6(c)(1) regarding refusal of informed consent.)

• Validity and duration of dental consent forms.

  • Procedure specific consent forms (i.e., CDCR 7424, 7425, 7426 and 7428) shall be valid for provision of the procedure(s) at any time and by any CDCR or contracted provider and shall remain valid until the procedure is completed.

  • The CDCR 7422 and CDCR 7429 shall be valid for provision of the treatment at any time and by any CDCR or contracted provider and shall remain valid for the duration of the sentence currently being served by the patient.

• In emergent situations, patients shall be treated under the law of implied consent.

Policy

• All California Department of Corrections and Rehabilitation dental departments shall operate in accordance with the California Dental Practice Act and ensure that all patient protection provisions of the Act are in force.  All dental services shall be rendered with consideration for the patient’s dignity and feelings and in a manner designed to ensure privacy of care in patient treatment and to encourage the patient’s subsequent use of dental services.

Purpose

• To establish guidelines and procedures dental clinics shall use to ensure privacy of care, when not in conflict with security and custodial policies, during patient dental treatment.

Procedure

• Patient dental treatment shall be performed as privately as possible, (i.e., only authorized Division of Health Care Services (DHCS) staff shall be present in the treatment area unless security necessitates the presence of a Correctional Officer).  A chaperon or interpreter shall be present when indicated.

• Photographing or videotaping of medical/dental procedures shall only be done with the written consent of the patient, and with the approval of the DHCS, and the local administration.  A formal Use of Force incident, where continuous video recording is used to document the entire event, shall be exempt from this requirement.

• Reference the Health Care Department Operations Manual, Section 3.1.5, Scheduling and Access to Care.

Policy

• Within the California Department of Corrections and Rehabilitation (CDCR), patient dental health information concerns shall be communicated by placing the appropriate order in the Electronic Dental Record System (EDRS), or by placing a 128-C chrono order in the Electronic Health Record System (EHRS). Dental Priority Classification information that could affect patient placement shall be documented by completing a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

Purpose

• To ensure that patients’ dental health information is documented, communicated and tracked in a systematic and uniform manner.

Procedure

• A CDCR dentist shall place:

  • A Dental Hold in the EDRS in accordance with EDRS Workflow 2-3 and associated Back Office Job Aid for patients described in the Health Care Department Operations Manual (HCDOM), Section 3.3.6.6(c)(2).

  • An order in the EHRS for a 128-C Dental Prosthetic for patients identified as having a pre-existing dental prosthetic appliance or for whom a dental prosthetic appliance is fabricated as part of an established treatment plan.

  • An order in the EHRS for a 128-C Dental Refusal subsequent to a patient’s refusal of treatment as outlined in the HCDOM, Section 3.3.5.6(c)(6).

• A CDCR dentist shall document a patient’s Dental Priority Classification in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, for situations outlined in the HCDOM, Sections 3.3.2.2(c)(1)(D)6 and 3.3.5.3(c)(9).

• Dental chronos shall not contain specific information regarding a patient’s health conditions in the body of the document.

Policy

• Patients within the California Department of Corrections and Rehabilitation who require medically indicated bed rest shall be provided with medical/dental lay-ins by institution licensed health care staff.

Purpose

• To establish standards and guidelines for the use of medical/dental lay-ins.

Procedure

• Medical/dental lay-ins shall be issued only by physicians, mid-level providers, Mental Health primary clinicians and psychiatrists, dentists, registered nurses, or licensed vocational nurses.  Medical/dental lay-ins shall be issued only to patients needing medically indicated bed rest or who temporarily cannot perform their assigned duties, but who do not require inpatient infirmary or hospital care.

• Institution licensed health care staff who are authorized to do so shall use the Lay-In PowerForm in the Electronic Health Record System for all medical/dental lay-ins.

• Medical/dental lay-ins shall be issued for specific time periods.  Dental lay-ins requiring confinement to quarters for longer than a 24-hour period shall be ordered only by a physician or a dentist, and the order must include a termination date.

• Upon expiration of the lay-in, the patient shall:

  • Return to normal activities or,

  • Be re-evaluated by the physician or dentist for possible reissue of a lay-in or,

  • Be re-evaluated by the physician or dentist for possible transfer to a facility with an infirmary or hospital.

• Patients on medical/dental lay-ins must be confined to their cells or dormitory beds, except to eat, obtain medication, shower, or to access the facility law library.

• Health care staff may re-evaluate the lay-in status of any patient at any time depending on the patient’s behavior and/or activity.

• Dental staff shall print the Lay-In PowerForm and distribute copies as follows:

  • Copy to Central File.

  • Copy to patient’s supervisor.

  • Copy to housing officer.

  • Copy to patient.

Policy

• The California Department of Corrections and Rehabilitation shall utilize a dental hold process when the transfer or transport of a patient is not clinically appropriate.

Purpose

• To establish procedures and criteria for placing dental holds on patients scheduled for transfer or transport.

Procedure

• The treating dentist in conjunction with the Supervising Dentist (SD) shall determine if a dental hold should be placed on a patient.

• A dental hold shall be placed on a patient for any of the following reasons:

  • The patient has untreated Dental Priority Classification 1A dental needs.

  • The patient has a dental condition that in the opinion of the treating dentist, in conjunction with the SD, requires immediate care.

  • Immediate dentures were recently inserted.

  • The patient is awaiting completion of endodontic treatment, (i.e., the obturation of canals).

  • The patient is awaiting an onsite or outside specialty consultation and/or treatment.

  • The patient is awaiting laboratory or biopsy results.

  • The patient is undergoing treatment for a fracture of the mandible or maxilla, and/or is still in wired fixation.

  • The patient is being referred to the Dental Authorization Review Committee.

• The SD shall review the health record and the Health Care Department Operations Manual (HCDOM) to ensure compliance with approved policies and procedures. (Reference the HCDOM, Section 3.1.9, Health Care Transfer).

• The treating dentist shall document the dental hold in a clinical note in the Electronic Dental Record System (EDRS) in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, and as outlined in the HCDOM, Section 3.3.6.1(c)(1)(F) through (H).  The dental hold shall be placed as outlined in the HCDOM, Section 3.3.6.4(c)(1)(A).

• The SD shall notify the Chief Executive Officer, or designee, of the placement or removal of a dental hold.

• The dental hold shall be closed only by the attending dentist, outside specialty consultant, or SD. When a dental hold has been placed and the patient refuses treatment of the condition that prompted placement of the hold, the SD or treating dentist shall close the hold in accordance with EDRS Workflow 2-3 and associated Back Office Job Aid, and document the incident as outlined in the HCDOM, Section 3.3.6.1(c)(1)(F) through (H).

• The procedure for placing or removing a dental hold on a patient is as follows:
  

  • The treating dentist or SD shall follow the process outlined in the HCDOM, Section 3.3.6.4(c)(1)(A) to initiate a dental hold which places a ‘Movement Warning’ in the Strategic Offender Management System (SOMS).

  • The Classification and Parole Representative (C&PR) shall contact Receiving and Release staff regarding the modification to the transfer list due to a dental hold.

  • Following completion of the procedure or treatment for which the hold was placed, the treating dentist or SD shall close the dental hold in accordance with EDRS Workflow 2-3 and associated Back Office Job Aid, thus releasing the patient for transfer.