Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Initial health history documentation should include

Oral health history documentation includes:

  • identification of oral health beliefs and practices
  • identification of the client’s oral health routine
  • 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
  • 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
  • frequency of oral care.