Dental Hygiene Audit

Audit your dental hygiene department's charting, coding accuracy, production, scheduling, recare, and collections with this ready-to-use checklist template.

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Dental Hygiene Audit



Patient Record Review (Spot Check)

1. Medical history is updated and signed for the visit being reviewed.


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2. A documented diagnosis or clinical rationale supports the treatment performed.


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3. Clinical notes describe the procedures carried out and explicitly support the codes billed.


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4. Periodontal charting is current and consistent with the level of treatment provided.


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5. Radiographs are present, of diagnostic quality, and dated appropriately for the patient's risk category.


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6. All clinical notes are signed off and finalised to provide a complete audit trail.


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7. Sterilization logs are verified and signed for all instruments used during the review period.


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8. Waterline testing and maintenance records are current and within acceptable parameters.


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Coding And Billing Accuracy (spot Check)

1. Procedure codes billed match the services performed and documented in the patient record.


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2. Preventive treatment (scale and clean) vs. periodontal treatment coding is applied correctly based on the patient's clinical status and treatment history.


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3. Scaling codes are supported by documented findings such as probing depths, bleeding on probing, or radiographic bone loss.


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4. Fluoride application is coded and billed when performed.


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5. Fissure sealants are coded and billed when applied.


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6. Radiograph codes match the type and number of images actually taken.


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7. Oral cancer screening is coded and billed when performed.


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8. All services performed during the visit have been marked as completed in the practice management software.


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Revenue And Production Tracking

1. Daily production figures reconcile with the procedures logged in the practice management system.


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2. The fee charged for each procedure matches the practice's current fee schedule.


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3. Production is credited to the correct clinician for payroll and performance reporting.


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4. Delegated procedures are documented and attributed to the supervising clinician where required.


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5. Hygiene department production for the review period is tracking to target.


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6. Missed revenue from declined or deferred treatment is recorded and flagged for follow-up.


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Scheduling And Recare

1. Hygienist schedules are booked to target capacity for the review period.


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2. Appointment durations are appropriate for the procedures scheduled.


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3. Cancellations and failed appointments are logged and followed up within the defined timeframe.


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4. Short-notice gaps are being filled from the waitlist or short-call list.


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5. Each patient has their next recare appointment booked before leaving the practice.


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6. Patients overdue for recare have been identified and contacted per practice protocol.


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Patient Billing And Collections

1. Outstanding patient balances are reviewed and followed up at defined intervals.


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2. Patient statements and invoices are issued promptly after treatment.


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3. Patients with overdue accounts have been contacted in line with the practice's collection protocol.


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4. Payment plans or flexible payment options are offered where appropriate and documented.


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Clinical Standards And Patient Communication

1. Periodontal assessments are carried out at the intervals defined by practice protocol.


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2. Where additional treatment or adjunctive therapy is indicated, the patient is referred to the dentist with documented findings.


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3. Treatment findings and tailored home care instructions are communicated to the patient and recorded.


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4. Unaccepted treatment recommendations are documented for follow-up at the next visit.


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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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