Basic info before initial assessment appointment. telephone screening.
Self-history:provide online, checked or circle
Complete History:made at initial visit combo of questionnaire and interview. review with patient
Types of record forms:
Basic history form:
available commercially or from ADA, or develop own.
Adequate basic history form:
conventional notation for important details. quick identification of special needs, pt owns words.
Supplementary form:
secondary more detail questionnaire about specialized topics.
History introduction to the patient:
Educate the patient why history is essential before treatment.
Convey the idea that oral health and general health are interrelated. effects
To build rapport , allow children to participate but most info comes from parent and signature.
Limitations of a history include:(reasons for inaccuracy or incompleteness of info)
Method of obtaining information (wording)
Language barrier
Location of data gathering
(no privacy)
Limited patient understanding
Reticence to disclose health information
(embarrassed)
The Questionnaire
Types of questions:
–System oriented: direct question determines if patient has had disease. specific..
–Disease oriented: Do you have or have you had any of the following?
–Symptom oriented: does your mouth frequently become dry?
–Culture oriented: referral, not needed
“Are you thirsty much of the time?,” is an example of which type of question in the health questionnaire?
Symptom oriented
Advantages of a Questionnaire:
Broad in scope
Time saving
Consistent
Patient may disclose more information
Legal document with patient’s signature
Disadvantages of questionnaire Without Follow-up:
Impersonal: no opportunity to develop rapport
Inflexible: no provision for additional questioning (great for school settings)
The Interview includes?
Participants
Setting
Pointers
Form
Participants in The Interview:
Participants: the interviewer is alone with the patient or parent of the child patient and, if necessary, a qualified professional translator/interpreter. The history is never to be taken in a reception area when other patients are present.
Setting in The Interview:
a consultation room or office is preferred; move the patient away from the atmosphere of the treatment room, where thoughts may be on the techniques to
Pointers for the interview in The Interview:
interviewing involves communication between individuals. Communication implies the transmission or interchange of facts, attitudes, opinions, or thoughts, through words, gestures, or other means. Through tactful but direct questioning, communication can be successful, and the patient will give all known information. Frequently, the patient is unaware of a health problem. The most effective attitude for the clinician to portray is one of friendly understanding, reassurance, and acceptance. Genuine interest and willingness to listen when a patient wishes to describe symptoms, complaints, or current health practices not only aids in establishing the rapport needed, but also frequently provides insight into the patient’s real attitudes and prejudices. By asking simple questions at first and more personal questions later after rapport has developed, the patient will be more relaxed and frank in answering. Self-confidence and gentle efficiency on the part of the interviewer help give the patient a feeling of confidence. Skill is required because tact, ingenuity, judgment, and cultural sensitivity are taxed to the fullest in the attempt to obtain accurate and complete information from the patient. The culturally sensitive dental hygienist will be aware of nonverbal communication issues when interviewing a patient from a different culture.
form in The Interview:
the interviewer may use a structured form with places to check and fill in. Another method is to record on blank sheets from questions created from a guide list of essential topics. Either type of form can involve reference to the positive or negative answers on a previously completed questionnaire. Familiarity with the items on the history permits the interviewer to be direct and informal without reading from a fixed list of topics, a method that may lack the personal touch necessary to gain the patient’s confidence. When appropriate, the patient’s own words are recorded.
Advantages/Disadvantages of the Interview:
Advantages
–Personal contact develops rapport
–Flexibility
Disadvantages
-Time consuming
–Omission of items of importance
–Patient embarrassment
Items Included in the History:
Information directly related to patient care
Age group would influence materials selected for care
Manifestations of systemic disease and medications influence care decisions,
Personal History, Dental History, Medical History
Items Included in the History: Personal History
Data collection for planning care
Need for informed consent
Need for physician consultation
Culturally appropriate communication determination
Items Included in the History: Dental History
Chief complaint
Previous dental and preventive care
Patient attitude toward oral health
Personal daily care
Patient’s current health beliefs
Items Included in the History:
Medical History
Conditions that complicate dental care
Disease requiring special precautions or premedication
Conditions requiring medicating drugs
–Influence care
–Contraindicate care
Gender or ethic/racial influences
–Increased risk for systemic diseases
Allergic or untoward reactions
Diseases/drugs with oral manifestations
Communicable diseases
Physiologic status of patient
Which type of patient would require antibiotic coverage during treatment?
C) A patient at risk for infective endocarditis is the correct answer.
Immediate Applications of History:
Care planning influences
Evaluation before clinical assessment
Essential for preparation of care plan
Immediate Applications of History:
Medical Consultation:
Dentist and physician need to consult relative to the patient’s current therapy and medications or to elements of the patient’s past health status that could influence present dental treatment needs.
Telephone or personal contact
Written request
Referrals
Immediate Applications of History:
Radiation
Recent therapy
Physician consultation
Rationale for radiographs
Immediate Applications of History:
Prophylactic Premedication
Risk for infectious endocarditis
Risk factors with invasive procedures
Routine use of antibiotics not indicated
Timing of ingestion of oral antibiotics
Recommendation for class of antibiotics
Principles of Pretreatment Antibiotic Prophylaxis
Risk in general population of infective endocarditis is low
Prophylaxis only for patients with underlying cardiac conditions
Used only for certain procedures
Medical Conditions Requiring Antibiotic Premedication
Prosthetic cardiac valve
Previous endocarditis
Congenital heart disease
Cardiac transplantation recipients with cardiac valvular disease
Procedures Requiring IE Prophylaxis for At-Risk Patients
Dental & dental hygiene procedures involving:
–Manipulation of gingival tissue
–The periapical region of teeth
–Perforation of the oral mucosa
Procedures NOT Requiring IE Prophylaxis for At-Risk Patients
Routine anesthetic injections
Taking dental radiographs
Placement of removable appliances
Adjustment of orthodontic appliances
Placement of orthodontic brackets
Shedding of primary teeth
Bleeding from trauma to lips or oral mucosa
ASA Determination
ASA Physical Status Classification System
–Categories I to VI
–Overall estimate of medical risk
ASA I:
a patient without apparent systemic disease: a normal healthy patient.
ASA II:
a patient with mild systemic disease.
ASA III:
a patient with severe systemic disease that limits activity but is not incapacitating.
ASA IV:
a patient with an incapacitating systemic disease that is a constant threat to life.
ASA V:
a moribund patient not expected to survive 24 hours with or without care.
Review and Update of History
Update at each appointment
Changes in health status with consideration for care plan
–Interim illness
–Visits to physician
–Lab test and results
–Changes in medication
–Changes in oral soft tissues and teeth
A person’s health is not static; therefore, a health history must be updated when or how often?
D) At each and every appointment
Documentation:
Date all entries
Permanent written records in ink
Patient signature for informed consent
Privacy of patient information
Coded tabs for health alerts
Plan for periodic revision of forms
Factors to Teach the Patient:
Need for obtaining complete histories prior to care procedures
