Introduction to Patient Evaluation and Assessment PDF

Marcia Rojas, DDS, MS, MPH Assistant Professor Division of Oral Diagnosis, Oral Medicine, and Oral Radiology ODM 814 A 23 YOF presented to clinic for her 6- month cleaning A 30 YOF presented to your clinic complaining of TMJ pain...

Marcia Rojas, DDS, MS, MPH Assistant Professor Division of Oral Diagnosis, Oral Medicine, and Oral Radiology ODM 814 A 23 YOF presented to clinic for her 6- month cleaning A 30 YOF presented to your clinic complaining of TMJ pain  A 27 YOM presented complaining of severe toothache and facial swelling  Types of Dental Examinations Comprehensive Examination Periodic Examination Problem-Focused Examination (limited) Types of Dental Examinations COMPREHENSIVE EXAM (D0150) - An in-depth assessment and recording of an individual’s chief -complaint, dental history, extraoral, intraoral, and soft tissue findings - Recommended for: - First visits - Patients who had a significant change in their health - Every 3 years thereafter - Is lengthy and detailed - Includes: - Medical history - Dental history - Periodontal examination - Dental examination - Soft tissue examination - Occlusal examination - Head and neck assessment - TMJ and masticatory muscle assessment - X-rays or other diagnostic procedures - Esthetic examination Types of Dental Examinations PERIODIC EXAM (D0120) - Performed on established patients to check if there are any changes to their dental or health status since their last evaluation - Recommended every 6 months Includes: - Updates in the dental history - Updates in the medical history - Updates in medication intake - Updates in dental/periodontal/soft tissue/other findings Types of Dental Examinations Problem-Focused Exam/Limited Oral Exam (D0140) - Addresses a specific dental complaint or acute need/problem - Gathers information about the health status but limits the dental examination - Potential situations include: - Oral lesion or wisdom teeth eruption - Dental emergency/urgency - Traumatic injury - Acute infection Which type of evaluation is recommended? A 23 YOF presented to A 35 YOM presented for A 30 YOF presented to A 27 YOM clinic for her a second opinion your clinic complaining of presented complaining of 6- month cleaning TMJ pain severe toothache and facial swelling  Dentistry Patients Out-patients In-patients Receive regular dental care Hospitalized patients without being admitted to a hospital The Diagnostic Process during Dental Exam Chief Complaint and HPI Medical/Dental/ Treatment Plan Social Histories Clinical Diagnosis Examination  Questionnaires & Forms Methods of Obtaining Patient interview Patient History Requesting information from another health care provider  Questionnaires & Forms Advantages Disadvantages Saves clinic time Information limited to questions Standardized method for data asked collection Incorrect answers No special skills required Misinterpretation Generic or custom made Not as comprehensive EHR can overcome some of the paper questionnaire disadvantages “Pop-up” menu for positive responses enables more data collection Patient Interview QUESTIONS CAN BE TAILORED TO EACH PATIENT THE PATIENT HEALTH, ORAL CARE NEEDS, THE INTERVIEW PROCESS HAS A LEVEL OF REQUESTS, AND CONCERNS ARE THE CENTER OF FORMALITY AND DEVELOPS QUITE DIFFERENTLY THE INTERVIEW FROM A PERSONAL CONVERSATION Open Ended Questions vs Closed Ended Questions Open Ended Questions How may I help you? Can you describe your pain? Can you tell me about your past dental care? Can you tell me more about your kidney problem? Closed Ended Questions Do any of your teeth hurt? Which tooth is sensitive to cold? Do you brush your teeth? Do you have shortness of breath? Do you take any medications?  Start by introducing yourself Good afternoon Mr. Jones, my name is … , I am a first-year dental student Ask what brings them to the clinic Interview Face your patient when you talk to them Ask about their expectations Process Eye to eye contact is important but defer from staring Be professional  To obtain accurate and complete information you should develop good communication skills You should be able to communicate with patients from different culture, gender, and socioeconomic backgrounds Use simple/plain language An interpreter (interpretation services) should be provided if Patient speaks a different language (not fluent in English) Patient requests an interpreter Provider deems it necessary  "Listening more than talking” is the golden role of an interview Information flow should not be interrupted unless no pertinent information is received (do it politely) Avoid influencing the patient response, be unbiased Establish a differential diagnosis from the history Be attentive, compassionate and aware of patient emotional responses and concerns Be aware of non-verbal communication (crossing arms and legs, facial expressions or avoiding eye contact) Interview s  Interview Errors Lack of clear introduction Ignoring patient’s emotions Failure to establish an atmosphere of trust Failure to establish professionalism Relying heavily on closed questions or leading questions Lack of knowledge  Interview Errors Influencing patient’s responses and early conclusions Interrupting the flow of the interview Distractions Providing premature treatment options Inadequate time management Patient History Get to know your patients “Never treat a stranger” Canadian physician Sir William Osler  Obtain a complete and accurate patient history Patient History Focus on pertinent information The complexity of data collection varies among patients Symptoms subjective Physical or mental problems experienced and reported by the patient Pain (toothache) Tooth sensitivity (cold, sweets) Bad breath Sensation of oral dryness Agitation Signs observable/measurable Objective findings are observed or measured by the provider during examination and may indicate that a person has a condition or disease Decayed tooth Swollen face Swollen ankles Difficulty breathing Bruises (ecchymosis) or bleeding Fever Patient History Confidentiality The Health Insurance Portability and Accountability Act HIPAA- 1996 aims to: Protect the Confidentiality and Security of Health Care Information 18 HIPAA identifiers, including: Patients name Geographical elements (address, city, county, zip code) Dates related to health, DOB, date of admission, date of death) Telephone numbers Fax numbers Email addresses Social security numbers Medica record numbers Health insurance information Account numbers Full face photographs