Registered Nurses' Association of Ontario

Documentation

  • Documentation will include recording in the client’s health record all information reflective of equipment and supplies being used.
  • The initial health history documentation should include, but not be limited to, the following:
    • Oral health history;
    • Oral health assessment; and
    • Oral health practices.
  • Oral health history documentation includes:
    • Identification of oral health beliefs and practices;
    • Identification of the client’s oral health routine; and
    • Whether the client has their own teeth or dentures (full or partial)
  • Oral health assessment documentation includes:
    • Physical assessment of the oral cavity;
    • The ability of the client to tend to oral hygiene independently; and
    • Identification of interventions required for the client to meet their oral hygiene needs (e.g. reminding, assisting, cuing or the provision of total care).
  • Oral health practices documentation includes:
    • Type of equipment used for oral care; and
    • Frequency of oral care.
Clinical Management
Oral Health: Nursing Assessment and Intervention
Point of Care Resources