4.5 Dental Charting Without Supervision: Locations, Form Content & Limits

Dental Charting — s. 466.0235, F.S., and Rule 64B5-16.0075, F.A.C.

Section 466.023(5) permits a hygienist to perform dental charting without supervision. Section 466.0235 defines what that means and sets its boundaries; Rule 64B5-16.0075 prescribes the paperwork.

The definition is a limitation — s. 466.0235(1)

"Dental charting" means "a recording of visual observations of clinical conditions of the oral cavity without the use of X rays, laboratory tests, or other diagnostic methods or equipment, except the instruments necessary to record visual restorations, missing teeth, suspicious areas, and periodontal pockets."

Every clause narrows the activity:

• Visual observations only. Not interpretation, not diagnosis.
• No radiographs, laboratory tests, or other diagnostic methods or equipment. A hygienist charting without supervision under this section may not take an X-ray as part of it. (Exposing radiographs is a general supervision task under Rule 64B5-16.006(7)(b) — a different activity requiring a dentist's authorization.)
• Instruments are permitted only to record visual restorations, missing teeth, suspicious areas, and periodontal pockets. This is the authority for a probe and mirror, and nothing beyond.
• The observations are recorded as "suspicious areas" — never as a diagnosis of caries or disease.

Where charting may occur — s. 466.0235(2)

A hygienist may perform dental charting of hard and soft tissues, without supervision and within the lawful scope of their duties, in:

• Public and private educational institutions of the state and Federal Government
• Nursing homes
• Assisted living and long-term care facilities
• Community health centres
• County health departments
• Mobile dental or health units
• Health access settings as defined in s. 466.003
• Epidemiological surveys for public health

And, separately: "A dental hygienist may also perform dental charting on a volunteer basis at health fairs."

This list is broader than the health access setting list in s. 466.003(15) — nursing homes and assisted living facilities appear here but are not health access settings. Do not merge the two lists.

The disclosure form — s. 466.0235(3) and Rule 64B5-16.0075(1)

Each person who receives dental charting — or the parent or legal guardian if the person is a minor — must receive and acknowledge a written disclosure form before the charting procedure. The statute requires the form to state that the purpose of the charting is to collect data for use by a dentist at a prompt subsequent examination, and to emphasise that diagnosis of caries, soft tissue disease, oral cancer, temporomandibular joint disease (TMJ), and dentofacial malocclusions will be completed only by a dentist in the context of delivering a comprehensive dental examination.

Rule 64B5-16.0075(1) prescribes the full contents:

Item (j) is the sleeper. Periodontal probing as part of dental charting requires documented medical clearance from a physician or dentist, recorded on the charting form itself. Charting without probing does not.

Epidemiological surveys — Rule 64B5-16.0075(2)

Hygienists charting and collecting data for epidemiological surveys for public health may use the charting forms without identifying patient information and without the name, licence number and place of employment of the hygienist or dentist. The public-health survey use case is deliberately de-identified.

Two disclosures, two statutes

Florida imposes disclosure obligations in two adjacent contexts, and the examination tests whether you can keep them apart.

The substance of the warning is nearly identical in both; the difference is the level of prescribed detail and the setting that triggers it.