{"id":1023,"date":"2023-11-06T09:59:58","date_gmt":"2023-11-06T17:59:58","guid":{"rendered":"https:\/\/www.cdcr.ca.gov\/hcdom\/?post_type=dom&#038;p=1023"},"modified":"2024-04-18T15:19:25","modified_gmt":"2024-04-18T22:19:25","slug":"3-3-6-1-health-records-organization-and-maintenance","status":"publish","type":"dom","link":"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-3-health-care-operations\/article-3-dental-care-6-health-services-record-management\/3-3-6-1-health-records-organization-and-maintenance\/","title":{"rendered":"3.3.6.1 Health Records Organization and Maintenance"},"content":{"rendered":"\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Policy<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Purpose<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Procedure<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>General Health Record Organization and Maintenance<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The health record shall contain the following:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identification data.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Problem List (including allergies, special needs, chronic illness clinics, permanent medical passes, non-English speaking status, etc.).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Receiving, screening and health assessment records.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Prescribed medication and therapeutic orders.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Reports of laboratory, radiographic and diagnostic studies.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Clinic notes.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Special needs treatment plans, if any.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Immunization records.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>All findings, diagnoses, treatment and dispositions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Informed consent, treatment refusal and release of information forms.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>All consultant\u2019s reports and procedural results.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Discharge summaries of inpatient admissions and hospitalizations.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Place, date and time of each health care encounter.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Signature, either electronic or handwritten, and title of each documenter.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Prior to seating a patient in the dental operatory, dental staff shall confirm each patient\u2019s identity by verifying the individual\u2019s 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>EDRS clinical notes shall be signed no later than close of business the day treatment is provided or observations are made.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.\u00a0 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>All dental health care providers shall utilize the Subjective, Objective, Assessment, Plan, Education format in documenting patient care.\u00a0 Entries made in a patient\u2019s 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:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Subjective \u2013 Patient\u2019s chief complaint or purpose of visit.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Objective \u2013 Objective findings.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Assessment \u2013 Diagnosis or clinical impression.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Plan \u2013 Proposed treatment plan.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Education \u2013 Patient education.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Only approved CDCR forms are authorized for inclusion in the health record.\u00a0 The practice of using unapproved forms or making modifications to approved forms is not authorized for permanent inclusion in the health record.\u00a0 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.\u00a0 This does not pertain to the filing of appropriate clinical information.\u00a0<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.\u00a0 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Dental Health Record Organization and Maintenance<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The following documents are authorized for scanning into the EDRS Document Center:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 237-F, Dental Pain Profile.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 239, Prosthetic Prescription.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7225-D, Dental Refusal of Examination and\/or Treatment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7342, Informed Consent to Surgical, Special Diagnostic, or Therapeutic Procedures.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7362, Health Care Services Request Form.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7423, Notification of Reception Center Dental Screening.\u00a0<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Dental Consent Forms<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7422, Informed Consent for Silver Diamine Fluoride Treatment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7424, Informed Consent for Root Canal Treatment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7425, Informed Consent for Extraction(s).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7426, Informed Consent for Periodontal Treatment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7428, Full and Partial Denture Agreement.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7429, Informed Consent for Dental Treatment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CDCR 7441, Patient Acknowledgement of Receipt of Dental Materials Fact Sheet.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PIA \u2013 CCW \u2013 006, PIA Prosthetic Prescription.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Proper and consistent documentation must be maintained to ensure compliance with applicable state and federal laws and regulations and DHCS, health record policy.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Health History Information<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>At the time of each initial or periodic comprehensive dental examination and prior to providing any dental treatment, a dentist shall review the patient\u2019s health history information in the EHRS and interview the patient using a standardized series of questions to validate the information.\u00a0<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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 \u2018Consult to Primary Care Provider\u2019 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Treatment Plan<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Authenticating Entries<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Dentists are authorized to authenticate any entry in the dental health record and are <em>required<\/em> to authenticate direct patient care entries, patient refusals of treatment, and rescheduling or cancellation of any encounter.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>(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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.\u00a0 They may sign the transcribed entry, but the appropriate dental personnel (dentist, RDH, [registered] DA) must authenticate the entry.\u00a0 Examples of such transcription include, but are not limited to, the following:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Entries pertaining to the receipt of a CDCR 7362 request.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Patient \u201cno show\u201d or \u201cfailed\u201d appointments.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Issuance of toothbrush, flossers, etc.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Clinical Notes<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.\u00a0 Examples of supplemental information include, but are not limited to:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Lab reports.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Recommendations.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Probable prognosis in doubtful or complicated cases.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Failure to keep an appointment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Failure to follow health care provider\u2019s instructions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Refusal of recommended treatment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Placement on lay-in status.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Appointments cancelled.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Treatment rendered.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Amount and type of anesthetic utilized.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Medication prescribed.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.\u00a0 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Revision History<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Effective: 04\/2006<br>Revised: 03\/2019, 11\/2020, 02\/2022<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendix 1: Approved CDCR Dental and Medical Forms<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDC 128-C, (MCV) Medical\/Psychiatric\/Dental.\u00a0 This chrono report shall be used for any pertinent notation that the attending practitioner requests be placed in the patient\u2019s EHRS or Central File.\u00a0 It is also used to record dental holds, a patient\u2019s refusal of treatment or refusal to appear for a priority appointment, as well as a patient\u2019s possession of a dental prosthetic appliance.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 237-A, (MCV) Reception Center Dental Screening.\u00a0 When downtime procedures have been implemented, this form shall be completed by the dentist as part of the initial dental screening of incoming patients at the RC.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 237-B, (MCV) Dental Examination and Treatment Plan.\u00a0 When downtime procedures have been implemented, dental staff shall use this form when completing a comprehensive dental examination.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 237-B-1, (MCV) Supplemental Dental Examination and Treatment Plan.\u00a0 When downtime procedures have been implemented, this form is used to note changes and additions to the dental treatment plan.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 237-C, (MCV) Dental Progress Notes.\u00a0 When downtime procedures have been implemented, this form shall be used to document clinical notes pertaining to dental treatments and visits.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 237-C-1, (MCV) Supplemental Dental Progress Notes.\u00a0 When downtime procedures have been implemented, this form provides additional space to document dental clinical notes.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 237-E, (MCV) Plaque Index (PI) Scoring Record.\u00a0 This form shall be used to record the patient\u2019s PI score.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 237-F, (MCV) Dental Pain Profile.\u00a0 This form is utilized by healthcare personnel to evaluate the level of pain associated with a patient\u2019s dental symptoms or for a stated dental emergency.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 239, (MCV) Prosthetic Prescription.\u00a0 This form must accompany each dental laboratory case sent to a California Department of Corrections and Rehabilitation (CDCR) dental laboratory during shipping and processing.\u00a0 The form must be completed, name stamped or name printed, and signed by the attending dentist, and must describe the prosthetic work to be performed by the dental laboratory.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDC 7221, (MCV) Physician\u2019s Orders.\u00a0 When downtime procedures have been implemented, this form is used to document verbal or written orders issued by licensed health care staff in the course of providing treatment to a patient. It is also utilized when requesting consultations or making referrals between medical and dental staff at an institution.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7225-D, (MCV) Dental Refusal of Examination and\/or Treatment.\u00a0 This form shall be completed when a patient refuses to submit to a dental examination and\/or dental treatment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDC 7243, (MCV) Health Care Services Physician\u2019s Request for Services.\u00a0 This form shall be used when requesting specialty consults or treatment by outside health care providers.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDC 7252, (MCV) Request for Authorization of Temporary Removal for Medical Treatment.\u00a0 \u00a0This form is completed by a Registered Nurse (RN) when it becomes necessary to transfer a patient to an outside facility for health care services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7257, (MCV) Medical\/Dental Lay-in Order. When downtime procedures have been implemented, this form shall be completed by a dentist to document that a patient is being placed on a medical\/dental lay-in. Use of this form is not necessary when the dentist elects to generate a CDC 128-C, (MCV) Medical\/Psychiatric\/Dental chrono for the lay-in.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7277, (MCV) Initial Health Screening (All Institutions).\u00a0 When downtime procedures have been implemented, this form shall be completed at Receiving and Release (R&R) by health care staff for all newly arriving patients, including new commitments and parole violators.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7277-A, (MCV) Initial Health Screening (Supplemental) \u2013 Female inmates.\u00a0 When downtime procedures have been implemented, this form shall be completed at R&R by health care staff for each newly arriving female patient, including new commitments and parole violators.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDC 7293, (MCV) Conditions of Admission\/Placement.\u00a0 This form shall be signed by each patient admitted to an inpatient setting, or placed in an outpatient-housing unit.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDC 7342, (MCV) Informed Consent to Surgical Special Diagnostic, or Therapeutic Procedures.\u00a0 This form shall be used by dentists as well as physicians.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7362, (MCV) Health Care Services Request Form.\u00a0 This form shall be used by patients to request a dental appointment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7385, (MCV) Authorization for Release of Health Care Record.\u00a0 This form shall be used by all patients requesting authorization for release of information from their health record, or from a previous health care provider.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7422, (MCV) Informed Consent for Silver Diamine Fluoride (SDF) Treatment. This form is to advise patients of the risks, benefits, or complications of SDF treatment and must be signed by the patient and the treating dentist prior to beginning SDF treatment. (Reference the HCDOM, Section 3.3.6.2(c)(2) for validity and duration of consent).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7423, (MCV) Notification of Reception Center Dental Screening. This form shall be completed by all RC patients diagnosed during the RC dental screening as having DPC 2, 3, or 5 dental needs to inform them that they could benefit from dental care.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7424, (MCV) Informed Consent for Root Canal Treatment.\u00a0 This form is to advise patients of the risks, benefits, or complications of root canal treatment and must be signed by the patient and the treating dentist prior to beginning the root canal. (Reference the Health Care Department Operations Manual (HCDOM), Section 3.3.6.2(c)(2) for validity and duration of consent).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7425, (MCV) Informed Consent for Extraction(s).\u00a0 This form is to advise patients of the risks, benefits, or complications of extractions and must be signed by the patient and the treating dentist prior to beginning the extraction. (Reference the HCDOM, Section 3.3.6.2(c)(2) for validity and duration of consent).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7426, (MCV) Informed Consent for Periodontal Treatment.\u00a0 This form is to advise patients of the risks, benefits, or complications of periodontal treatment and must be signed by the patient and the treating dentist prior to beginning the periodontal treatment. (Reference the HCDOM, Section 3.3.6.2(c)(2) for validity and duration of consent).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7428, (MCV) Full and Partial Denture Agreement.\u00a0 This form is to advise patients of their eligibility, and to outline the requirements for having full or partial dentures made.\u00a0 The form must be completed and signed by the patient and the treating dentist prior to taking impressions for full or partial dentures. (Reference the HCDOM, Section 3.3.6.2(c)(2) for validity and duration of consent).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7429, (MCV) Informed Consent for Dental Treatment.\u00a0 This general consent form is used to advise patients of the risks, benefits, or complications of dental treatment and must be signed by the patient and a dentist prior to beginning dental treatment. (Reference the HCDOM, Section 3.3.6.2(c)(2) for validity and duration of consent).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7431, (MCV) Periodontal Chart.\u00a0 When downtime procedures have been implemented, this form shall be completed as part of a comprehensive periodontal examination.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7441, (MCV) Patient Acknowledgement of Receipt of Dental Materials Fact Sheet (DMFS).\u00a0 This form shall be signed by each patient upon receipt of the DMFS.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7443, (MCV) Dental Health History Record \u2013 English. \u00a0When downtime procedures have been implemented, this form shall be completed when treatment is rendered and shall list any past or present illnesses, medications currently being taken, or allergies to medications, etc.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>CDCR 7444, (MCV) Dental Health History Record \u2013 Spanish.\u00a0 When downtime procedures have been implemented, this form shall be completed by Spanish speaking patients when treatment is rendered and shall list any past or present illnesses, medications currently being taken, or allergies to medications, etc.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>PIA \u2013 CCW \u2013 006 (MCV) Prosthetic Prescription. This form must accompany each dental laboratory case sent to the PIA Dental Laboratory during shipping and processing. The form must be completed, name stamped or name printed, and signed by the attending dentist, and must describe the prosthetic work to be performed by the dental laboratory.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t","protected":false},"parent":522,"template":"","class_list":["post-1023","dom","type-dom","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>3.3.6.1 Health Records Organization and Maintenance - Health Care Department Operations Manual (HCDOM)<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"3.3.6.1 Health Records Organization and Maintenance - Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-3-health-care-operations\/article-3-dental-care-6-health-services-record-management\/3-3-6-1-health-records-organization-and-maintenance\/\" \/>\n<meta property=\"og:site_name\" content=\"Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"article:modified_time\" content=\"2024-04-18T22:19:25+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-3-health-care-operations\\\/article-3-dental-care-6-health-services-record-management\\\/3-3-6-1-health-records-organization-and-maintenance\\\/\",\"url\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-3-health-care-operations\\\/article-3-dental-care-6-health-services-record-management\\\/3-3-6-1-health-records-organization-and-maintenance\\\/\",\"name\":\"3.3.6.1 Health Records Organization and Maintenance - Health Care Department Operations Manual (HCDOM)\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/#website\"},\"datePublished\":\"2023-11-06T17:59:58+00:00\",\"dateModified\":\"2024-04-18T22:19:25+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-3-health-care-operations\\\/article-3-dental-care-6-health-services-record-management\\\/3-3-6-1-health-records-organization-and-maintenance\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-3-health-care-operations\\\/article-3-dental-care-6-health-services-record-management\\\/3-3-6-1-health-records-organization-and-maintenance\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-3-health-care-operations\\\/article-3-dental-care-6-health-services-record-management\\\/3-3-6-1-health-records-organization-and-maintenance\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"HCDOM\",\"item\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/\"},{\"@type\":\"ListItem\",\"position\":3,\"name\":\"Chapter 3 &#8211; 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