Emergencies & Records - Outcome 3 - Week 3 PP Flashcards

1
Q

What’s in a Health History?

A

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

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2
Q

Importance of a Medical History

A
  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
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3
Q

Obtaining a Health history

A
  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
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4
Q

Signs & Symptoms

A
  • 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.

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5
Q

Legal and Ethical Responsibilities

A
  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
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6
Q

Advantages of a Questionnaire & Interview

A
  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
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7
Q

The Personal History

A

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

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8
Q

The importance of personal history

A
  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
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9
Q

Dental History

A

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

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10
Q

Medical History - Why?

A
  • 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
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11
Q

Questions on a dental history?

A
  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?
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12
Q

Common Investigating Questions

A
  1. When?
  2. What?
  3. Why?
  4. How was it resolved?
    A patient’s positive response must be investigated
    further
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13
Q

What are Medical Alerts for?

A

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

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14
Q

SAIT Medical Alerts

A
  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.
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15
Q

Updating a Health History

A
  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.
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16
Q

Updating Health History Questions

A
  • 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?