RDH 101 Week 10 Course Objectives

RDH 101 Week 10 Course Objectives

• Complete and Accurate Medical and Dental History:

  • Includes demographic info (name, contact, gender, DOB, insurance, physician info, referral source)
  • Records social history (marital status, occupation, living situation, cultural practices, social determinants)
  • Documents chief complaint in the patient's own words, which is the primary reason they seek oral care
  • Records personal history (previous conditions, treatment, frequency of visits, experiences, self-care habits, beliefs, values, type of diet)
  • Includes medical health history, documenting overall medical health, prescriptions and OTC medications, and reasons for consultation
  • Includes risk assessment factors such as antibiotic allergies, cardiovascular disease.

• Patient Record as a Legal Document:

  • Accurate and detailed documentation is crucial for legal purposes.
  • Accurate records are vital for diagnosis and care planning.
  • Initial assessments, baseline data, and overall health are recorded at first visit.
  • Tracking assessment over time is essential.
  • All findings, health, emotional status, and risk factors are also documented.
  • Assessing oral health status, including diagnosis (various conditions) facilitates patient care planning.

• Risk Assessment Related to Oral Disease:

  • High-risk conditions include antibiotic allergies, cardiovascular disease, and the need for prophylactic antibiotic premedication.

• Purpose of Recording Personal, Dental, and Health Histories:

  • Initiating the assessment process starts upon the patient being called to the exam room.
  • Understanding patient concerns, goals, and attitudes is important.
  • Documenting baseline information at the first visit is necessary to track over time.
  • Evaluating physical and emotional health, and nutritional status is key.
  • Obtaining patient rapport is vital.
  • Identifying risk factors and necessary precautions is a critical component of care.
  • Facilitates diagnosis and care planning for various conditions.

Health History Assessment

• Dynamic and Ever-Evolving:

  • Needs constant monitoring for changes.
  • Health history interviews are essential for establishing trust and rapport.
  • Includes patient-centered interviewing.
  • Maintaining patient well-being is a mutual goal.

• Patient-Centered Interviewing Techniques:

  • Important for eliciting patients' emotions, concerns, personal health agendas, and perceived disease.
  • Includes empathetic listening, and active verbal and nonverbal communication, with honesty and without bias.

Health Literacy

• Basic Reading and Numeracy Skills:

  • Crucial for understanding health information.
  • Patients with poor health literacy require verbal confirmation.

• Capacity to Obtain, Process, and Understand Information:

  • Essential for making informed health decisions.

• Important for patients to accurately understand their care plan.

Social Determinants of Health and Clinician's Role

• Risk Factors Identification:

  • Smoking, work stress, and poor living conditions may negatively affect patient willingness and ability to seek dental care.

• Interview Setting:

  • Promoting privacy and discretion is critical for sensitive discussions.
  • Patient's confidentiality is essential.
  • Proper settings are required for minors.

Motivational Interviewing and Techniques

• Modify Patient Behavior:

  • Motivational interviewing is a technique used during the interview process to encourage positive change.

• Change Talk:

  • Encourages patients to discuss their own desires, ability, reasons, and need for change.

• Back Channel Communication

  • Active listening is essential for patient engagement during patient-doctor interactions.

• Open-Ended Questions:

  • Designed to encourage deeper dialogue between patient and healthcare provider.

Chief Complaint

• Primary Reason for Seeking Oral Healthcare:
  • Patient's explanation of oral health concerns, expressed in their own words, is documented.

ASA Physical Status Classification:

• Medical Risk Categorization:
  • A six-tiered system to assess medical risk.
  • The system considers existing medical conditions, functional limitations, and blood pressure for patients requiring local or general anesthesia.
  • Provides a framework for determining whether, when, and how to treat patients.
  • Based on ASA categories, specific dental treatment could be recommended, avoided, or delayed until risk factors are controlled.

Functional Capacity Assessment

• Medical Risk Assessment:
• Cardiovascular, respiratory, chronic health conditions
• Assessment of capacity to undergo dental procedures, and treatment.

Prophylactic Antibiotic Premedication

• Preventative Measures:
  • Administered to prevent bacteremia (bacteria in the blood) and infection.
  • Used for patients with specific cardiac conditions (prosthetic cardiac valves, history of infective endocarditis etc)

Antibiotic Premedication Not Recommended

• Situations in Which It's Not Recommended:
  • Conditions such as non-functioning heart murmur, certain dental procedures or treatments are excluded from recommendation.

Physician Consultation and Need

• When Necessary:
  • Conditions requiring antibiotic premedication; undiagnosed conditions requiring reevaluation; abnormal vital signs; anticoagulant or blood-thinning medication use, any health condition that could jeopardize safety.

Dental Referrals

• When Necessary:
  • When undiagnosed conditions or further examination is needed to effectively deliver oral care.

Patient History (Demographic and Social Status):

• Includes name, contact information, gender, date of birth, marital status, occupation, living situation, cultural practices, insurance information, previous dental providers, physician information, and referral source.
  • Crucial components used to aid care planning.

Review Patient Dental History and Chief Complaint

• Relevant Questions: Includes questions focusing on previous dental care, radiation history, dental complications, patient anxiety, chewing ability, periodontal health, oral lesions, oral habits, patient satisfaction, and facial/oral injuries.

Review Patient Health History:

• General health: Includes general questions about overall health, changes in health, last physical examination results, current medical care, serious illnesses/hospitalizations, medical radiation, medications, allergies and reactions, etc.
• Medical conditions: Encompasses detailed questions about cardiovascular disease, cardiac valves, infective endocarditis, congenital heart conditions, valvular disease in transplant recipients. All related questions covering specific conditions are included and appropriate action is detailed. Information like type of treatment, symptoms, and when the condition started.

Record Keeping and State Requirements

• Documentation requirements: Includes state requirements for record keeping, and suggestions/guidelines on patient record management
• Record accuracy and legibility: Clear documentation using permanent ink, correcting errors, adhering to time constraints as needed. Secure storage procedures for confidential patient records, including proper handling of errors.

Decision Making After Obtaining Health History

• Interpretation: Involves analyzing patient data, risk evaluation, understanding medication effects (especially related to premedication), and when physician consultation and collaborative care planning are essential for complete patient care (individualized oral hygiene plan).

This quiz covers essential course objectives for RDH 101, focusing on completing and accurately documenting medical and dental histories. It highlights the importance of patient records as legal documents and their role in diagnosis and care planning. Understanding these components is vital for aspiring dental hygienists.