Chapter 11 Medical, Dental, and Psychosocial Histories PDF

Chapter 11 Medical, Dental, and Psychosocial Histories  Learning Objectives Define key terms utilized in the creation of patient histories Explain the purpose of complete patient medical, dental, and psychosocial histories Compare and contrast methods available for...

Chapter 11 Medical, Dental, and Psychosocial Histories  Learning Objectives Define key terms utilized in the creation of patient histories Explain the purpose of complete patient medical, dental, and psychosocial histories Compare and contrast methods available for the compilation of patient histories Discuss how patient histories relate directly to the application of patient care  Purpose of the History For safe, evidence-based dental and dental hygiene care, a thorough patient health history is an essential part of the complete assessment. The history directs and guides steps to be taken in preparation for, during, and following appointments  Purpose of the History The history is needed to determined if antibiotic premedication is indicated before the use of instruments that would manipulate the soft tissue around the teeth.. Consultation with the patient’s primary care provider if a question exists about the medical history as described by the patient, or when an unusual or abnormal condition is observed Identifies when even emergency treatment must be postponed or kept to a minimum until the patient’s medical status is determined.  Purpose of the History Continued Provide information for the etiology and diagnosis of oral conditions Reveal conditions that necessitate precautions, modifications, or adaptations during appointments Aid in the identification of possible unrecognized conditions Permit appraisal of the general health and nutritional status Reveals emotional and psychological factors, attitudes, cultural beliefs, ethnics and prejudices that may affect present appointments as well as continuing care. Used for reference and comparison over a series of appointments  Significance of the History Oral conditions reflect the general health; dental procedures may complicate or be complicated by existing pathologic or physiologic conditions General health factors influence response to treatment (tissue healing) The state of the patient’s health is constantly changing. History must be updated continually.  Limitations of a History Problems in method of obtaining the histories; such as how the questions are worded Difficulty reading or has a language barrier. The patient’s limited knowledge and inability to understand the relationship between certain diseases or conditions and dental treatment. Information may seem irrelevant and is withheld Reluctance to discuss a condition that may be embarrassing, such an infectious or communicable disease.  History Preparation The general methods in current use for obtaining a health history are the interview, the questionnaire (which may be paper or electronic). A combination of the two is best. Forms are available commercially or from the American Dental Association (ADA) for a fee, but many prefer to develop their own and have a form printed to their specifications  Types of Questions System oriented Disease oriented Symptom oriented Culture oriented  The Questionnaire Positive findings explained further in personal interview Questionnaire cannot fully satisfy overall purposes of history Can provide basic information Advantages Disadvantages of a Broad in scope Questionnaire (If Used Time saving Alone without a Follow- Consistent Up Interview) Legal aspects Impersonal Inflexible  The Interview The interviewer is alone with the patient or parent of the child patient Seat patient comfortably in upright position Clinician needs to be friendly understanding, reassurance, and acceptant Genuine interest and willingness to listen Follow up on any “yes” answers with further questions, document answers Interview Advantages and Disadvantages Advantages Disadvantages Contributes to Time consuming rapport with patient Items can be Flexible to patients omitted individual needs Patient may feel uncomfortable or embarrassed  Items Included in the History Dental History (Table 11-1) Medical History (Table 11-2) Psychosocial History (Table 11-3) SPEND SOME TIME IN THESE TABLES Application of Patient Histories Medical Consultation- phone, written, or referrals Radiation Prophylactic Premedication Risk of Infective Endocarditis What is Infective Endocarditis? Why should we be concerned? Copyright © 2017 Wolters Kluwer All Rights Reserved 16  Pretreatment Antibiotic Prophylaxis AHA Guidelines; updated 2014 Medical Conditions that Require Antibiotic Premedication before Invasive Dental and Dental Hygiene Procedures BOX 11-2 Recommended Antibiotic Protocol TABLE 11-4 Copyright © 2017 Wolters Kluwer All Rights Reserved 18  Procedures for which Endocarditis Prophylaxis IS Recommended All dental and dental hygiene procedures that involve: Manipulation of gingival tissue The periapical region of teeth Perforation of the oral mucosa need antibiotic premedication  Procedures for which Endocarditis Prophylaxis IS NOT Recommended Routine anesthetic injections through noninfected tissue Taking dental radiographs Placement of removable prosthodontic or orthodontic appliances Adjustment of orthodontic appliances Placement of orthodontic brackets Shedding of primary teeth Bleeding from trauma to the lips or oral mucosa American Society of Anesthesiologists Determination ASA I: a patient without apparent systemic disease: a normal healthy patient. ASA II: a patient with mild systemic disease. ASA III: a patient with severe systemic disease that limits activity but is not incapacitating. ASA IV: a patient with an incapacitating systemic disease that is a constant threat to life. ASA V: a moribund patient not expected to survive 24 hours with or without care.  Review and Update of History Essential at each appointment Record changes in health status Direct questions to determine and compare from previous medical history (important to use correct verbiage): Changes in health/illnesses Visits to physician/reasons Laboratory tests/A1c Current medications/changes in dosage Changes in oral soft tissues and teeth noted by the patient  Documentation Date all records Write in ink Store electronic patient records on secure server on password-protected computer Record patient signature Maintain strictest privacy Coded tab systems for premedication alerts or flags on electronic record Evaluate form periodically