Emergencies & Records - Outcome 3 - Week 3 PP

Question 1

What’s in a Health History?

Answer 1

A collection of patient information that includes:
1. Personal history
2. Medical / Health History
3. Dental history

Question 2

Importance of a Medical History

Answer 2

1. Prevents medical emergencies
2. Assists in dental diagnosis
3. Guides dental treatment
4. To recognize signs and symptoms of
   different conditions and diseases.
5. Directs possible need for referrals

Question 3

Obtaining a Health history

Answer 3

1. Questionnaire to be answered by the patient
2. Dental health care worker Interviews the patient
   and asks follow-up questions
3. Dental health care worker observes the patient

Question 4

Signs & Symptoms

Answer 4

• Signs are objective evidence of a disease which means others observe it.
• Signs can be visible and observable by the health care
  professionals.
• Signs are measurable

*Symptoms are subjective evidence of a disease which means it’s only what a person can feel.
* Symptoms cannot be measured; they are only felt.

Question 5

Legal and Ethical Responsibilities

Answer 5

1. The patient’s Health History is a legal contract obliging the
   patient to report any changed their health or medications.
2. A date and signature of the patient (parent/guardian) and
   the dentist or dental hygienist is a MUST for the
   document to be considered legal. ASSISTANTS CANNOT SIGN OFF ON A MEDICAL HISTORY

Question 6

Advantages of a Questionnaire & Interview

Answer 6

1. Time saving: long-term
2. Consistent
3. Patient may disclose more information
4. Legal document with patient’s signature
5. Educate patient
6. Convey the relationship of oral and general
   health
7. Personal contact develops rapport

Question 7

The Personal History

Answer 7

Contains the patient’s personal information
1. Full name
2. Date of birth
3. Contact information
1. Telephone numbers
2. E-mail address(es)
3. Emergency contact(s)
4. Physicians contact information
5. Previous dentist contact information

Question 8

The importance of personal history

Answer 8

1. Essential for appointment planning, booking, and
   insurance requirements
2. Possible consultations with all healthcare
   providers
3. Age – legal considerations, treatment planning
4. Personal medical emergency contact

Question 9

Dental History

Answer 9

Information about the patient’s previous
dental treatment and care how the patient
feels about dentistry and how important
dental care is to him or her

Identifies:
1. Current dental concerns
2. Previous dental care
3. Adverse effects related to dental care
4. Personal attitude and daily oral hygiene care

Question 10

Medical History - Why?

Answer 10

• complicate certain kinds of dental and dental hygiene
  treatment
• require special precautions or premedication before
  treatment
• require medicating drugs that may influence or
  contraindicate certain procedures
• have gender or ethnic/racial influences that increase
  the risk for systemic and oral disease
• have allergic or untoward reactions
• conditions that manifest in the oral cavity that may be communicable and endanger the dental healthcare
  professional
• influence the physiologic state of the patient

Question 11

Questions on a dental history?

Answer 11

1. Time frame of last appointments?
2. Reason for present appointment?
3. How often do you brush/floss your teeth
4. Do you wear a removable appliance?
5. Do you have any concerns with your teeth, gums
   or jaw?

Question 12

Common Investigating Questions

Answer 12

1. When?
2. What?
3. Why?
4. How was it resolved?
   A patient’s positive response must be investigated
   further

Question 13

What are Medical Alerts for?

Answer 13

Conditions that…
1. Require special precautions
2. May contraindicate treatment
3. May complicate treatment
4. Risk of a medical emergency

Question 14

SAIT Medical Alerts

Answer 14

1. Only the supervising dentist/dental hygienist can designate a patient record/chart as a medical alert.
2. If a student suspects a possible medical alert (MA), they are to red star the condition on the Patient History note page.
3. The supervising dentist/dental hygienist will note the medical alert by, placing a red star next to the medical alert on the medical and dental history form and by writing the medical alert on the upper right corner of the patient chart in red pen.
4. A red tab will also be placed on the chart, three slots from the tag color-coded to indicate the patient’s first letter of their last name.
5. Medical Alert designation must reflect a potential medical
   emergency during the procedure or must have an impact on
   dental treatment.
6. The medical alert will be recorded in the patient’s electronic file.

Question 15

Updating a Health History

Answer 15

1. Must be done every appointment
2. Have there been any changes in your health,
   such as any serious illnesses, hospitalization, or
   new allergies? If yes, please specify.
3. Are you taking any new medications or has there
   been any change in your medications? If yes,
   please specify.

Question 16

Updating Health History Questions

Answer 16

• Have you had a significant weight change in the last 12 months?
• Have you had a new heart problem diagnosed or had any
  change in an existing heart problem?
• Have you a history of infective endocarditis and/or placement of a prosthetic cardiac valve?
• Have you had an artificial joint replacement?
• Have you traveled outside of the country recently? If yes, have you had any illness since or other symptoms such as a cough?
• When was your last medical checkup?
• Were any problems identified? If yes, please explain.
• For women only: Are you breastfeeding or pregnant? If
  pregnant, when is the expected delivery date?
• Are there any other conditions or problems of which the
  clinician should be made aware?