Infection Control and Recordkeeping Obligations
Domain 4 tests infection control and the chart. Illinois incorporates the CDC dental infection-control guidelines and the OSHA bloodborne pathogens standard, and the rules require records that let another clinician reconstruct care.
Infection control
Standard precautions apply to every patient. Required elements include hand hygiene, gloves, masks, eye protection, gowns when splash is likely, safe sharps handling, and no recapping by hand. Critical and semicritical instruments must be cleaned and sterilized; sterilization must be monitored, with biological spore testing at least weekly and records kept. Single-use needles and carpules are not reused. Waterlines require the maintenance the guidelines specify.
Recordkeeping
The chart must record history, examination findings, diagnosis, treatment, anesthesia, radiographs, prescriptions, and informed consent. Records are confidential and must be retained for at least five years from the last treatment, and longer for minors under the rules. Patients are entitled to copies on proper request.
Worked example
A hygienist treats patients all morning without a mask because only clean prophies are scheduled. Standard precautions do not depend on the procedure label; mask and eye protection are required whenever splatter or aerosol is likely, which includes ultrasonic scaling and air polishing. The omission is both an infection-control violation and evidence of unprofessional conduct.
Traps
- Treating CDC guidance as optional because it is not a statute.
- Conflating OSHA worker protection with CDC patient and worker safety.
- Charting prophy done with no findings or consent.
- Destroying records at five years when the patient is a minor.