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a systematic literature review. Gerodontology.

Documenting oral care

As with any other patient-care process, oral care should be documented. But our documentation system lacked a place to record the type and frequency of oral care provided. So we enlisted staff to redesign the documentation of basic nursing care in the medical record. The redesign was piloted and refined repeatedly until staff were satisfied.

Documenting oral care also was essential for monitoring our quality-improvement project and determining the impact of oral care on NV-HAP rates. To reinforce the importance of oral care, we conducted unit audits to monitor oral-care delivery, related issues, and barriers to providing adequate oral care on HAPPI units.


We completed an oral-care knowledge and attitude survey before the oral-care intervention to determine the staff’s educational needs. Results were telling: The majority of our nursing staff didn’t know we had an oral-care protocol and few nurses were aware of the link between oral microbes and pneumonia. (We recommend including nurses’ aides in surveys and comprehensive education sessions in hospitals where they provide basic oral care.)

We then developed an oral-care education program in collaboration with the local dental society (which served as an expert resource). The program covered HAP causes and prevention, our new oral-care protocol, and demonstration of our new oral-care equipment, which empowered staff to deliver this valuable basic intervention.

We also developed a patient and family education program, which included a poster and flyers detailing the importance of oral care during hospitalization. We placed the posters in elevators and hallways and used the flyers in one-on-one education sessions with patients and family members.