Person: _________________________________       Completed by: ________  /________  / ________       Date:  ________  /________  / ________

Dentist: _________________________________        Phone: _________________________________            

Date of last dental appointment:  ________  /________  / ________           Date for next oral health care plan review:  ________  /________  / ________

• At the top of the form, please write in the following:
  • Name of the older person
  • Name of the person completing the OHCP
  • Date the OHCP was completed
• Enter the name of the older person's dentist and the dentist's contact phone. If they do not have a dentist, write "No current dentist."
• Enter the date of the older person's last dental appointment. If the date is not known, write "Unknown."
• Write in the date for the next OHCP review.
  • Complete the OHCP initially at a baseline time with older people that are new to your care. 
  • Complete the OHCP again at 8 weeks, and ongoingly as you decide what care is required for that individual. 

Practice using the Oral Health Care Plan (OHCP) by viewing the form for Mrs. Rose East, who is being admitted to your nursing home.

Mrs. East has Alzheimer's disease, and forgets to clean her teeth and her dentures, so she needs others to help her do this. She has a complete upper denture and a partial lower denture, which she insists on wearing day and night. Several of her bottom front teeth remain, but one of these teeth has broken off. She has a very dry mouth. She last saw a dentist on March 11 of last year, but the dentist she saw has since moved away.

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