Prescriptive Supervision Scenarios

Using Prescriptive Supervision in Your Practice

prescriptive_supervisionDr. Leslie Shane is a 39-year old general dentist who has a busy practice in northwest Indiana. She employs an expanded duties assistant, Marla, and two hygienists, Kristy, who’s been with Dr. Shane since she opened her office 12 years ago, and Darlene, who joined the practice when she graduated from IUSD’s hygiene program 18 months ago.

 

Dr. Shane’s weeks are hectic and often include as many as 14 patients each day. On top of that, her son Timothy is on the school basketball team and needs to be picked up after practice three times a week, and her daughter Amanda just won the lead in the school play. Ever since her husband Matt started practicing at a new law firm on the opposite end of town, most of the kid-related responsibilities have fallen to Leslie. So she was very excited to hear about Indiana’s new prescriptive supervision law.

 

Dr. Shane is looking forward to taking advantage of prescriptive supervision in her office. She has grown tired of juggling kid duties with a busy practice and she already has several scenarios in mind in which prescriptive supervision will come in very handy:

 

Scenario 1

Next Tuesday, Amanda’s drama club will be presenting a practice run of their play for parents only. It will be a great chance for the kids to experience a live audience before their actual opening night. The performance is scheduled for 2:00pm. Unfortunately, when Leslie checked her schedule, she discovered that Kathy Smith is scheduled for her biannual appointment. Kathy is a great patient who has been coming to Dr. Shane since she first opened her practice. She is extremely compliant and takes her oral health very seriously. Leslie and Kathy have gotten quite friendly, commiserating over each other’s busy lives. In fact, when Kathy was in six months ago, she told Leslie how exhausted she’s been since she started helping take care of her elderly grandmother. Leslie knew that it would be a major inconvenience to ask Kathy to reschedule. But then she remembered prescriptive supervision and realized she wouldn’t need to reschedule. Kathy can come in for her regular 2:00 appointment and get her prophy with Kristy as usual. Her oral health was excellent, Leslie noticed nothing unusual during her last exam six months ago, and there was very little chance there would be any caries this time around. Leslie would simply call Kathy, explain the situation, and let Kathy know she would write up an order so she could come in for her cleaning as scheduled.

 

Scenario 2

Leslie also noticed that Sam Helm was scheduled for his biennial appointment at 2:30 on Tuesday. Leslie wasn’t sure what to do about that appointment. She knew if she went to see her daughter’s play, she’d never be back in the office by 2:30. But she didn’t feel right about leaving her staff to deal with Sam on their own; he could be a bit cantankerous. Sam was only 62 years old, but Leslie suspected he suffered from the early signs of Alzheimer’s. For the past two years he had been very agitated and would snap at the staff for apparently no reason. He got easily confused, and during his last appointment he forgot Leslie’s name, even though he, too, had been a patient since Leslie opened her practice and came in regularly for his appointments. But his dental health was excellent, and Leslie knew he would only need a cleaning. Kristy could easily handle it on her own, Sam would never even have to know that Leslie wasn’t there. In fact, it would be better not to mention it to him, just to make sure he didn’t get snappy. Leslie would write up an order, keep it in Sam’s chart, and he could get his prophy as usual.

 

Scenario 3

Now that Tuesday’s schedule was taken care of, Leslie checked the schedule for Wednesday. On Wednesdays, Leslie liked to stop at the bank during her lunch hour. But the bank was usually crowded at lunchtime, which often caused Leslie to arrive late for her 1:00 patient. She saw that Mark Everly was scheduled for 1:00 on Wednesday. That would work out perfectly, Leslie thought. She could run to the bank, and if she got held up she would have her assistant Marla get started with the x-rays. Leslie would then do the exam when she got to the office and the rest of the afternoon wouldn’t get backed up.

 

Scenario 4

Dr. Shane remembered a new patient, Brian, who came in for emergency treatment last week. Brian explained that he hadn’t seen a dentist since he last had dental insurance four years ago. He had been experiencing terrible tooth pain for over three weeks, but was trying to hold off treatment until his new dental insurance went into effect. Since he just recently started his new job, he’d still have to wait two and a half months for his insurance to be effective. Unfortunately for Brian, the pain had gotten worse and his cheek started to swell, so he knew he couldn’t wait any longer. Dr. Shane gave Brian a thorough exam, diagnosed and removed the decay, and restored the tooth all within a payment plan that Brian was able to manage. He wanted to hold off on his prophy until his insurance kicked in, and asked if he could make an appointment for Friday, December 4. Even though Dr. Shane’s office is typically open on Fridays, that particular Friday she is scheduled for an all-day CE course. But now Dr. Shane realized she just needed to write and sign the order, keep it in Brian’s chart, and he could come in to see Kristy for his prophy on December 4.

 

Scenario 5

As long as she was going to schedule Brian for a prophy on December 4, Dr. Shane decided to review her patient records and schedule a few additional prophies. There were several patients she had seen within the past seven months who would be ready to come in for their cleanings. And, this would be the perfect opportunity for her hygienist Darlene to get a little more experience. Darlene joined Dr. Shane’s practice approximately 18 months ago, as soon as she graduated from the IUSD hygiene program. She showed a lot of promise, but since she had only been working part-time since she and her husband adopted a baby five months ago, Leslie noticed she had lost a bit of confidence. She thought this would be a great opportunity for Darlene to work directly with the patients without feeling intimidated by Leslie’s presence. She didn’t want to overwork the girls, so she decided to schedule five prophies for Kristy and four for Darlene.

 

Scenario 6

Leslie started thinking about how valuable prescriptive supervision could be to her practice. She figured she could use it on a regular basis each Thursday. Thursdays are their late days; Leslie keeps the office open until 7:00 p.m. as a convenience to many of her patients. Unfortunately, from mid-September through January, Timothy needs to be picked up from basketball practice at 5:30 on Thursdays. In the past, they would close the office and the staff would take a break while Leslie left to pick up Timothy. But now Leslie realizes she can actually schedule patients during that time frame. Kristy can get started with prophies and Dr. Shane will finish up with the exams when she returns to the office.

 

Scenario 7

Leslie and her family take vacation every year at the beginning of July. It’s always a large family gathering with Leslie’s extended family, and has been a tradition since Leslie was a little girl. She knew it was a bit of a financial burden and inconvenience to her staff to require them to take their vacation time along with hers. Leslie wanted her own kids to experience the family tradition, but she had been seriously considering forgoing the trip the following year, just to make it fair on her staff. She now realized she wouldn’t need to cancel her trip or force the staff into a vacation schedule that wasn’t convenient for them. Instead, she would schedule her recall patients for prophies during her vacation time. Leslie’s plan would be fairly easy to carry out, since they always tried to schedule recall as the patients left their current visit. Starting in December, when they scheduled recall, they would simply notify applicable patients that only a cleaning was needed on the next visit. They would offer an appointment during the first week of July, and notify the patient that Dr. Shane would not be available. If the patient agreed, they would schedule the cleaning, and then three weeks before her scheduled vacation, Leslie would sit down and write the orders, sign them and keep them in the patient records. The patient would come the first week of July for the prophy, and then schedule the next recall appointment for six months later, at which time Leslie would provide another comprehensive exam.

 

Scenario 8

Leslie was also confused about something she heard during her last component meeting. She was told that the new law prevented hygienists from using lasers when treating patients. She often had Kristy check her patients with the DIAGNOdent in conjunction with regular x-rays. She assumed Kristy would no longer be able to use the DIAGNOdent.

 

Leslie has great plans for using prescriptive supervision to benefit her practice. But which of these scenarios is a legitimate use of the law?

 


Scenario 1

In the first scenario, Dr. Shane will be out of the office when her recall patient Kathy comes in for her scheduled cleaning with Kristy. This scenario is an acceptable use of prescriptive supervision because it complies with the regulation’s criteria:

 

 

  • Kathy was examined six months ago. Prescriptive supervision may be utilized when “a licensed dentist: (A) has: (i) in a dental office setting, provided the patient with a comprehensive oral examination and any appropriate care in the previous seven (7) months.”
  • Kathy was notified that Dr. Shane would not be present. In a dental office setting, it is mandatory that the office has “notified the patient that the licensed dentist will not be present when the dental hygienist is providing the patient care.”
  • Dr. Shane will write the order, sign it and file it in the patient record. According to the law, “the dentist’s written order must be recorded, signed, and dated in the patient’s records.”

 

Scenario 2

In scenario two, Dr. Shane was concerned that her pre-dementia patient would get agitated if he discovered Leslie was not in the office. She decided, in the interest of the staff and patient, they would not even mention Leslie’s absence. This is not an acceptable use of prescriptive supervision. The law requires that the office has “notified the patient that the licensed dentist will not be present when the dental hygienist is providing the patient care.”

 

Scenario 3

In the third scenario, Leslie was worried she might be a few minutes late returning from the bank. Rather than having her patient wait, she decided to have her assistant Marla begin with the x-rays. Leslie would then complete the exam, diagnosis and treatment as soon as got into the office. This is not an acceptable use of prescriptive supervision. Under certain circumstances, “a licensed dentist is not required to be physically present in the facility when patient care is provided by the dental hygienist.” Prescriptive supervision does not apply to dental assistants.

 

Scenario 4

In scenario 4, Dr. Shane planned to have her new patient Brian, whom she just examined a few weeks ago, come to the office for his prophy while she attends an all day CE course. This is an acceptable use of prescriptive supervision because:

 

  • Brian was recently examined. The law requires that the dentist provide a “comprehensive oral examination and any appropriate care in the previous seven (7) months.”
  • Brian will be notified “that the licensed dentist will not be present when the dental hygienist is providing the patient care.”
  • Leslie will write, date and sign her order in accordance with the stipulation that “the dentist’s written order must be recorded, signed, and dated in the patient’s records.”

 

Scenario 5

In the fifth scenario, Leslie decided to schedule several prophy patients for both her hygienists while she attends her CE course. Leslie’s plan is only partially acceptable. Scheduling recall patients who have been examined within the past seven months for prophies with Kristy is appropriate. On the other hand, Darlene, who has only been practicing hygiene for 18 months and is now working part-time, is not eligible to work under prescriptive supervision. The law requires that the hygienist has worked an average of at least 20 hours for at least two years. However, it does not specify that the two years must be the current two-year period. If your hygienist has 14 years of experience and has been working 15 hours per week for the last three years, she is eligible to work under prescriptive supervision since she has met the average 20 hours for at least two years qualification.

 

Scenario 6

In scenario six, Dr. Shane must leave the office to pick up her son from basketball practice. While she’s gone, Kristy will get started with prophies, and Leslie will examine the patients when she returns to the office. This is an acceptable use of prescriptive supervision for all patients, regardless of when they were last examined, because Leslie will examine Kristy’s patients when she returns to the office. “Nothing in subdivisions (2)(A)(i) or (2)(B)(i) prohibits a dental hygienist from providing patient care before the licensed dentist provides the comprehensive oral examination if the licensed dentist provides the comprehensive oral examination on the same day that the dental hygienist has provided the patient care.” Keep in mind that all other stipulations still apply: the hygienist must have averaged at least 20 hours a week for at least two years, the patient must be notified that the dentist is not present, and the dentist’s order must be dated, signed and filed in the patient’s record.

 

Scenario 7

In scenario seven, Dr. Shane planned to schedule her recall patients for prophies while she is away on vacation. Leslie’s plan is acceptable provided that:

  • All patients scheduled during this time have received a comprehensive exam within the past seven months, and
  • All patients scheduled during this time are notified that Dr. Shane will not be present, and
  • Leslie writes, dates, signs and files her orders no more than 45 days before the appointment. The law stipulates the dentist must write a “written order for the specific care to be provided that is valid for not more than forty-five (45) days and provided in a dental office.” And
  • All prophies are to be performed by Kristy since Darlene is not eligible to work under prescriptive supervision. If, at the time of Leslie’s vacation, Darlene has met the 20 hours for two years regulation, she will then be eligible to work under prescriptive supervision.

 

Scenario 8

In the final scenario, Dr. Shane was disappointed that Kristy would no longer be able to use the DIAGNOdent with her patients. Fortunately, that is not the case. House Enrolled Act 1282, which went into effect July 1, 2015, clarified the laser regulation by stating “a dental hygienist may not use a laser to cut, ablate, or cauterize hard or soft tissue to provide treatment to a patient.” Because the DIAGNOdent does not cut, ablate or cauterize, Kristy is not prohibited from using it.

 

Editor’s Note: The spirit of this law was to aid the dental practitioner with slightly more freedom and liberty. It is very easy to see how the law change could become fragmented and create quite a slippery slope for the profession.

 

Please refer to HB 1061 and HB 1282 for the complete law regarding Prescriptive Services. Remember to use the privileges accordingly, and not like Dr. Shane haphazardly did.