Patient Presentation and Evaluation Flashcards
What is the SOAP note format?
● Subjective
● Objective
● Assessment
● Plan
What is the subjective part of SOAP?
● CC
● HPI
● MH/PMH/PSH/PDH
— Medications
— Allergies
— Tobacco / ETOH / Recreational Drugs
● Assessment of anxiety
● ROS
What is the objective part of SOAP?
● Physical Examination (Examine the patient)
— X-Rays
— Labs
What is the assessment part of SOAP?
Diagnosis
What is the chief complaint?
Why is the patient there?? What do they want?
What is HPI?
history of present illness
What does the HPI (history of present illness) concern?
●Further describes, supports, provides information about the chief complaint
● What treatment had been performed in the past, related to the chief complaint
●If pain is involved, where, when, what exacerbates, what resolves, what is the character of the pain
What do you find out about past dental treatments?
may be identified during the HPI (history of present illness)
What does the medical history and past medical history?
Past and current medical history: “the patient’s past and current experiences with illnesses, operations, injuries and treatments“.
●Includes:
- Medications
- Past Surgical History (if contributory)
- Allergies
- Social History
- Family History (if contributory)
What are the primary tools of the provider to assess the patients current and past medical history, overall level of health, and risk for treatment??
● The written Medical History
● The Patient Interview
What is a medical history questionnaire?
■ A tool to gather written information about the patient’s health
■ Completed by the patient or the patient’s guardian
■ Simple format which is easy to understand
■ Two standard formats:
● short
● long
What is the patient interview?
An opportunity to review the responses made on the written medical questionnaire
● To better understand, and gain better understanding of specific responses on the medical questionnaire
● Will provide the interviewer the opportunity to cross check any inconsistent responses
What are the benefits of the patient interview?
■Promotes dialogue
● To gain greater insight to the magnitude of the problem(s)
● Develops rapport
● Assesses anxiety fear and phobia
Who should conduct the patient interview?
the person…
● Planning to conduct the treatment
● Planning to administer the anesthetic
Why are patient medical histoy/interview so important?
■ Provide snapshot of the patients general state of health
■ Ascertain level of anxiety
■ Assessing the patients exercise tolerance will provide a direct correlation to the patient’s ability to tolerate dental treatment
■ Identifies any treatment altering, treatment limiting or treatment postponing health issues of the patient that the provider has to manage.
■ Identifies the risk involved in treating the patient
■ Identifies where consultations may be required
What allows for you to identify what systemic diseases/disorders the patient has which requires treatment/management by their physician/primary care provider or medical specialists?
med history/past medical history
What allows you to place a patient in a ASA classification?
med history/past medical history
What is ASA I?
normal, healthy patient
ex: (No systemic disease)
What is ASA II?
patient with mild systemic disease which is well controlled
ex: (well controlled hypertension)
What is ASA III?
patient with significant systemic disease which limits activity but not incapacitating
ex: (congestive heart failure)
What is ASA IV?
patient with an incapacitating systemic disease which is a constant threat to life
ex: (unstable angina pectoris)
What is ASA V?
moribund patient not expected to survive more than 24 hours
ex: (end stage kidney disease)
What is important to find out about medications?
- What medications are used to manage or control the systemic disorders
- Assess the degree of control on patient’s systemic disease
- The more categories of medication needed to control or optimize a particular systemic disease process, the more significant the process is
- Identify medications which might alter or impact dental treatment (Monoclonal antibiotics)
- OTC Meds
- Herbal and holistic medications should also be listed
The more categories of _____________ needed to control or optimize a particular systemic disease process, the more significant the process is
medication
What is important to find out about allergies?
● allergies to any medicines or substances must be noted.
- The provider must be able to discriminate allergic responses to medicines from side effects
-Latex
What is important to find out about social history?
- Tobacco
- Alcohol
— Use must be quantified
— For surgery patients increased use of tobacco and alcohol may impact healing - Recreational Drugs
— Cardiovascular events
What are options for patient fear and anxiety?
● Hand holding (non pharmacological methods)
● N2O/O2
● Oral medications/Oral Pre Meds
● Intravenous medications
● General Anesthesia
● Combinations of the above
What is ROS (review of systems)?
An inventory of specific body systems performed in the process of taking a history from the patient.
What is the purpose of the ROS (review of systems)?
● to bring out clinical symptoms which the patient may have overlooked or forgotten.
● Focus upon the subjective symptoms perceived by the patient ● Based on the 11 recognized organ systems
What does the physical examination involve?
● Starts when the patient walks in the room
● Must include vital signs
- Blood pressure
- Pulse
- Labs
- Other measurable components (INR, BGL)
What does the dental examination involve?
● Making a disposition on the current oral cavity state of repair
● Creating a problem list
What is involved in the radiographic examination?
■ Panoramic radiograph
■ Periapical x-rays
■ Bitewings
■ CBCT
■ Other x-rays
Why is the radiographic exam important?
● Identifies clinically important factors only observable on the radiograph
● Factors which will have impact on the extraction of the teeth.
● Placement of implants
How do the x-rays need to look/be?
- Current radiographs
- Diagnostic radiographs
What should you be able to see in a radiographic exam?
■ Will demonstrate the density of the alveolar bone
■ Shows the state of repair of the teeth which cannot be ascertained clinically
■ Demonstrates the presence of previous endodontic treatment
■ Identifies the presence of periapical pathology
■ Demonstrates abnormal root morphology
■ Identifies tooth root ankylosis
■ Relationship of tooth roots to other important structures
■ Radiographically identifying the positions of impacted teeth or third molars
What are some labs you might need?
*Coagulation panels
— INR
*BGL
— Current level of Blood glucose
*AIC
— Measure of Long term diabetic control
*CBC
What is the diagnosis for SOAP?
● Create a problem list
● Medical needs first (as needed)
- Medical concerns which may require optimization before treatment
- Important for good notes to keep the provider on point
- Will be able to carry forward pending actions
- Address medical problems first before addressing dental problem.
- Appropriate consultations
● Dental treatment needs
● Have in the plan all interventions needed to address all problems
What do medical consultations usually request to evaluate?
● Ability to tolerate treatment
● Medical clearance to proceed
● Modify existing medication regimens prior to the procedure
- Level of anticoagulation
- Insulin
How do you adequately write a med consult?
- You are NOT asking MD for start check
- You are NOT asking permission to initiate dental treatment
- You ARE to Communicate with other health care professional
What are the steps to write a med consult?
- Step 1: Write an abbreviated S.O.A.P. note
- Step 2: Brief anticipated procedure
- Step 3: Ask the focused question and what you want to know
- Step 4: Print and Fax ( Yes! FAX, not email)
How do you create the treatment plan?
- Create a sequenced plan to address the items on the problem list
— Putting all factors together to make an optimal plan when able or the best plan as needed - Make sure other treatment options were discussed…and documented
— Need good informed consent - Consultations as needed
- Referrals as needed
- Work within comfort and skill levels
- Execute the treatment as determined by the plan
Is no treatment an option?
Yes
* Individual risks can usually be managed
* When risks are stacked that can be a problem
* Don’t be a cowboy or cowgirl…refer!!!!
What is important to know about risk assessment?
Know your patient
* If you need more time to gather health information…take it
* Assessment of systemic diseases can impact treatment
* Consultations when necessary
Is it ok to “draw your line in the sand” and not do a procedure if the risk assessment is too much?
Yes
* Stay within your level of comfort
* Its always easier when you are watching someone else doing it
* No good deed goes unpunished
* Detailed informed consent
— Especially with patients with higher risk factors
— Detailed treatment notes…take the time
* Its OK to say no
