History Taking/Record Keeping

Question 1

What do patient records include?

Answer 1

1. Histories/Complaints
2. Record of treatment carried out
3. Clinical findings
4. Charts
   
   1. Dental
   2. Periodontal
5. Radiographs
6. Consent
7. Referral letters
8. Attendance/non attendance/cancellations

Question 2

What information should we cover from the records before seeing the patient?

Answer 2

Familiarise yourself with notes/histories

1. Check prescription from GDP
2. Check treatment
3. Check LA
4. Are radiographs available?
5. Antibiotic prophylaxis required?

• Be prepared for likely complaints

Question 3

What categories of information (headings) are covered in patient history?

Include relevant details for each heading

Answer 3

Patient history includes: Add more from notebook

1. ID (Name, Age, DOB, Address)
2. PCO (Patient Complaining of)
   
   1. Reason for visit:
      
      1. Patient referred for particular complaint?
      2. Pain?
   2. Where?
   3. Transient/Constant?
   4. When did it start?
   5. What makes it better/worse?
   6. What have you been doing to manage?
   7. Any particular problems associated with complaint?
3. PDH (Past Dental History)
   
   1. Registered with dentist?/Regular attender at DDH?
   2. Attendance:
      
      1. How often do you visit? (irregular attender = only when in pain)
      2. Last visit?
      3. Many FTAs?
   3. Previous treatment?
   4. Anxiety/problems with LA?
   5. Oral Hygiene
      
      1. How often do you brush your teeth?
      2. For how long?
      3. Type of brush (hardness of bristle, electric/manual)
      4. Any bleeding?
      5. Floss? How often?
      6. What kind of toothpaste?
      7. How often do you change your toothbrush?
      8. Note any fixed dental appliances - do they remove dentures?
   6. Any recurring complaints? Take note of
      
      1. Bleeding
      2. Increased probing depth
      3. Caries
      4. Areas of pain
4. SH (Social History)/Habits
   
   1. Smoker?
      
      1. When started?
      2. How many (pack years)?
      3. Have they tried to stop/do they want to?
   2. Alcohol?
      
      1. How many units/week?
   3. Sugary foods/drinks?
      
      1. How often?
      2. Any areas of wear on teeth?
      3. May need to ask patient to fill in a diet diary
   4. Occupation/Stressors?
   5. Hobbies
      
      1. Relevant if causes erosion/abrasion: pipe smoker, musician, joiner
5. PMH (Past Medical History)
   
   1. Registered with GP?
   2. Filter out what is particularly dentally relevant
   3. Allergies? (LA, latex, materials)
   4. Any medical conditions? (particularly: heart complaints, rheumatic fever, bleeding problems)
   5. Currently taking any medications? (may interact with LA e.g. betal blockers)
6. FH (Family History)
   
   1. Family history of medical/dental problems? (gum disease/any family members lost teeth early?)

Question 4

How often is the medical history renewed and updated?

Why (consequentially)?

Answer 4

A new Medical History form must be filled in yearly

Additionally, it must be updated at each visit

One of the most common litigation cases is failure to update medical history

Question 5

Why is smoking relevant dentally?

Must dentists advise patients regarding the risks of smoking?

Answer 5

Smoking very relevant dentally –

1. oral cancer,
2. periodontal disease,
3. dry mouth,
4. calculus

As a health-care professional, you have a responsibility to advise your patients about the health risks associated with smoking

Question 6

What is a pack year

How is pack years calculated?

Why is pack years used as a measurement?

Answer 6

A pack years is smoking 20 cigs per day (a pack) for one year

Number of pack years =

• no. of packs per day x no. of years smoker
• no of cigarettes per day x no. of years smoker/20

Quantification of pack years smoked is important in clinical care where degree of tobacco exposure is closely correlated to risk of disease.

Question 7

Why is one’s alcohol consumption relevant?

How is alcohol consumption recorded?

How is a unit calculated?

Answer 7

Alcohol has been shown to be a high risk factor for oral cancer

Alcohol consumption is recorded in units per week (not day)

Units in a drink = ABV% x Vol (ml) / 1000

Question 8

What constitutes valid consent?

How can consent be given?

Answer 8

For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision.

The meaning of these terms are:

• voluntary – the decision to either consent or not to consent to treatment must be made by the person, and must not be influenced by pressure from medical staff, friends or family
• informed – the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead
• capacity – the person must be capable of giving consent, which means they understand the information given to them and can use it to make an informed decision

Consent can be given:

verbally – for example, a person saying they’re happy to have an X-ray

in writing – for example, signing a consent form

Question 9

What do the following abbreviations mean?

1. PCO
2. PMH
3. PDH
4. STE
5. IO
6. EO
7. NAD
8. OH
9. OHI
10. Triangle (delta)
11. TX
12. LA
13. FS
14. BW
15. PA
16. POIG

Answer 9

1. PCO = patient complaining of
2. PMH = past medical history
3. PDH = past dental history
4. STE = soft tissue examination
5. IO = intraoral
6. EO = extraoral
7. NAD = nil abnormal detected
8. OH = oral health?
9. OHI = oral health instructions
10. Triangle (delta) = diagnosis
11. TX = treatment
12. LA = local anasthesia
13. FS = fissure sealant
14. BW = bitewing
15. PA = periapical
16. POIG = post op instructions given?