- 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.
Oral Health: Nursing Assessment and Intervention
Point of Care Resources