4.1 Supervision Levels, the Patient-of-Record Rule, and the Dentist's Responsibility

The three-part delegation test

The outline's task T108 asks you to supervise auxiliaries in accordance with regulations, using "procedures used to supervise auxiliaries" (K1082). Before any auxiliary treats a patient, three questions must all be answered "yes":

1. Is this duty within this auxiliary's legal scope? (Section 4.2)
2. Is the person a patient of record, or does an exception apply?
3. Is the required level of supervision in place?

If any answer is "no," the auxiliary is practicing beyond their license and the dentist is aiding it. That is unprofessional conduct under B&P § 1680(c) (aiding unlicensed practice), § 1680(d) (aiding a licensee to practice unlawfully), and § 1680(y) (aiding negligent or incompetent practice).

Supervision levels

Two details are frequently tested:

• Physical presence means in the facility, not at the chair. The dentist does not have to watch every step, but must be on site. A dentist at lunch across the street is not providing direct supervision.
• Checking the work. Board regulations for many intraoral assisting duties say the procedure must be performed "pursuant to the order, control and full professional responsibility of the supervising dentist" and checked and approved by the dentist before the patient is dismissed (16 CCR §§ 1085(c), 1086(d), 1087(c)). Unlicensed coronal polishing requires the dentist to evaluate each patient afterward (B&P § 1750(f)(4)(A)).

For RDAs, the statute lets the supervising dentist decide whether each duty listed in § 1752.4(a) is performed under direct or general supervision (§ 1752.4(d)). Registered dental hygienists work under general supervision for any procedure that does not specifically require direct supervision, unless the situation calls for immediate relief of severe pain or immediate diagnosis of an unforeseeable condition (§ 1912).

Nitrous oxide has its own rule. A dental assistant may not start the flow of nitrous oxide and oxygen, but may adjust it when directed by a supervising dentist who is present in the operatory (§ 1750.1(b)(16), (d)(5)).

The patient-of-record rule

B&P § 1684.5(a) makes it unprofessional conduct for a dentist to perform, or allow to be performed, any treatment on a person who is not a patient of record. A patient of record is someone who has been examined, has had a medical and dental history completed and evaluated, and has had oral conditions diagnosed and a written plan developed by the licensed dentist (§ 1684.5(b)).

Before the dentist's examination, auxiliaries may still do the following if it is within their classification:

• Procedures necessary for diagnostic purposes, after the dentist's preliminary oral exam.
• Emergency radiographs on the dentist's direction.
• Radiographs chosen by an RDAEF, RDH, or RDHAP to help the dentist complete a diagnosis and treatment plan through telehealth (§§ 1753.55, 1910.5, 1926.05).
• Extraoral duties the dentist specifies.
• Mouth-mirror inspections, including charting obvious lesions, malocclusions, existing restorations, and missing teeth.

The rule does not apply to temporary screenings outside an office, such as health fairs and school screenings, or to school fluoride rinse programs (§ 1684.5(e)–(f)).

Care delivered away from the dentist's office

When an RDAEF, RDH, or RDHAP provides care at another location under the dentist's diagnosis and treatment plan, the authorizing dentist must make sure the patient or representative gets written notice that the care was given at the dentist's direction, including the dentist's name, practice address, and phone number (§ 1684.5(c)). A dentist may concurrently supervise no more than five RDAEFs, RDHs, or RDHAPs providing these telehealth-linked services (§ 1684.5(d)).

Responsibility stays with the dentist

• Competence: the supervising dentist is "directly responsible for determining the competency" of a dental assistant (§ 1750(b)).
• Training records: the employer must make sure an unlicensed assistant completes the required infection control course or exam before any procedure with exposure to blood or saliva, and must keep proof for the length of employment (§ 1750(c)–(d)).
• Licenses: using anyone to perform the functions of an RDA, RDAEF, orthodontic assistant, dental sedation assistant, RDH, RDHAP, or RDHEF who lacked a valid license or permit at initial employment is unprofessional conduct (§ 1680(ae)). Letting someone operate X-ray equipment without meeting § 1656 is unprofessional conduct under § 1680(o).
• Ethics: the ADA Code, Section 2.C, requires dentists to assign only duties that "can be legally delegated" to qualified auxiliaries and to "prescribe and supervise the patient care" they provide.

The auxiliary is also accountable. Licensed auxiliaries can be disciplined for exceeding their scope, and an unlicensed assistant who performs licensed procedures is practicing without a license. "The doctor told me to" is not a defense for either of them.

Worked scenario

Dr. Patel has a morning emergency and leaves the office at 10:00. Still in the office are an RDH seeing a recall patient, an RDA placing a sealant on a new patient the dentist has not examined, and an unlicensed assistant polishing a patient's teeth.

• RDH recall scaling: permitted under general supervision (§ 1910), because the patient is a patient of record.
• RDA sealant on a new patient: not permitted. The person is not a patient of record, so § 1684.5 bars treatment regardless of supervision level. Sealant placement also requires the RDA's sealant course (§ 1752.4(b)(4)).
• Unlicensed coronal polishing: not permitted, because it requires direct supervision and a post-procedure evaluation by the dentist (§ 1750(f)(4)(A)).