Midterm I: Written Documentation + Health history

Question 1

why are good health records valuable

Answer 1

• record for progress of care
• communicates info to other healthcare professionals
• plays increasingly important role as health insurers depend on diagnostic and procedures codes from these records for reimbursement
• legal document of history, diagnosis, and treatment for defense of lawsuits

Question 2

what does SOAP stand for why does it matter

Answer 2

subjective (what patient tells you)
objective (what you see or measure)
assessment (what you conclude)
plan or procedure (what you did or will do)

• -will present it this way in clinic
• • use soap format for alll subsequent treatment/patient contact

Question 3

what is included under S of soap

Answer 3

subjective: 
what they tell you--- 
ID= identifying data (age,sex , ethnicity)
CC=chief concern
HCC=history of chief concern
MH=medical history
DH=dental history
SH=social history

Question 4

what is included under O of SOAP

Answer 4

what are YOUR observations:
-EX= ALL exams performed: clinical intra and extra oral, radiographic, periodontal, hard tissue, occlusal examinations, risk assessment for perio and caries, laboratory test results

Question 5

what is included in A of SOAP

Answer 5

assessment - whats your DIAGNOSIS =DX

• based on S and O what do you conclude?
• perio DX= perio diagnosis and risk assessment
• CRA = caries disease diagnosis and risk assessment
• occlusion/tmj assessment
• restor dx= restorative needs, surgical/non surgical
• etiology= causes of each of the above
• prognosis = ideal outcome of treatment of each of the above

Question 6

what is included under P of SOAP and what do DWP, RBAs and ABCs stand for?

Answer 6

plan/procedure
-treatment plan - include phases/sequence, ethical considerations, further diagnostic steps

DWP- discussed w patient,
RBAs= risk and benefits of alternatives
ABCs= alternatives with benefits and complications

Question 7

what is oral diagnosis

Answer 7

science of assessing patients needs , ART Of learning who patient is/what diseases -medical and dental- they may have or be at risk of getting. what treatment, dental/medical will be best for them

Question 8

what is the first step of oral diagnosis and what 5 things do we want to achieve

Answer 8

talking to them!

1. chief concern
2. history of chief concern
3. medical history
4. dental history
5. social history

Question 9

what is the second stage of oral diagnosis and whats involved (6-12)

Answer 9

examine patient:

6. physical exam: how they look, vital signs, head and neck/extraoral and intraoral exam
7. radiographic exam
8. clinical exam: periodontal and hard tissues, occlusion
9. assessment of findings
10. formulate differential diagnosis
11. narrow down to definitive diagnosis, use diagnostic tests
12. formulate a treatment plan

Question 10

what is a resource for drug reference for dentistry

Answer 10

lexi-comp!

Question 11

what must occur after a patient fills out a health history form? why?

Answer 11

it needs to be followed up with a VERBAL interview by the doctor.

• to insure patient properly understood questions
• to ask about any positive responses
• to insure that a negative response was what the patient intended for certain questions

—not recommended to alter or make notations on the patients health questionnare. notes of significant findings is made in EHR medical history record

Question 12

what are 6 questions that should be asked of EVERY patient VERBALLY

Answer 12

1. cardiovascular problems?
2. infectious diseases?
3. allergies to medicines (or latex)?
4. bleeding problems?
5. take any medication?
6. other medical problems not asked about?
   - - must make sure the patient understood the questions in the questionnare, best to talk verbally

Question 13

why are cardiovascular issues important? what specifically should be addressed?

Answer 13

comprises bulk of medical issues that require dental management considerations. 51% of patients w/med complexities have CV issues. rapidly increases with age.
-patients shoudl be asked “heart problems blood/bleeding problems, heart surgery, or circulation problems”

Question 14

what is the most common infectious disease w dental implications?

Answer 14

hepatitis

Question 15

what other allergies should patients be asked about

Answer 15

antibiotics, pain meds (aspirin), narcotics, local anesthetics, latex, foods

Question 16

why is it important to ask about medication, what drug-drug interaction risks are there

Answer 16

indicates that a medical issue is severe enough to require medical treatment. and dentist will know if theres side effects, toxicity, lesions or durg interactions that may occur during dental care.

Question 17

what drug-drug interaction risks are there in dentistry

Answer 17

1. metronidazole and fluconazole with warfarin (a blood thinner) -risk of internal bleeding
2. NSAIDs and Lithium (lithium is used to treat bipolar depressive disorder, NSAIDs may cause lithium toxicity , potential renal failure, GI distress, CNS disorders)
3. epinephrine and propanolol (pindolol) - nonselective beta blockers prevent skeletal muscle vasodilatory compensatory effect of epinephrine on blood vessels, increasing overall peripheral blood pressure

-ask about chemo and biphosphonate meds especially!!!!!

Question 18

what over the counter/natural things are common and have dental implications

Answer 18

gingko, st johns wort, evening primrose, valerian

-patients wont mention unless asked

Question 19

1. over 65 med statistics
2. diet supplements
3. how common is discussing complementary or alternative medicine with healthcare providers

Answer 19

1. 58% take 5-9 meds per week, 18% take mroe than 10 per week
2. 1/3 of americans take dietary supplements
3. 50+ age, 67% didnt discuss it. 42%-clinicians didnt ask. 30%-they didnt know they should. of those that discussed it, patient initiated the convo 2x more than clinician

Question 20

what should you ask after medical review

Answer 20

any medical problems not asked about?

-may then talk about anxiety w dentist, establishing raport etc

Question 21

what are ASA1-ASA6 meanings

Answer 21

ASA 1: a normal/healthy patient
ASA 2: a patient with mild systemic disease (or a significant health risk factor)
ASA 3: a patient with severe systemic disease that limits activity but is not incapacitating
ASA 4: a patient with severe systemic disease that is a constant threat to life
ASA 5: a patient who is not expected to survive 24 hours with or without medical intervention
ASA 6: a declared brain dead patient whose organs are being removed for donor purposes

Question 22

four basic questions to answer regarding safety of proceding with treatment

Answer 22

1. will the patient be able to endure the physiologic (and psychologic) stress of the procedure?
2. will the patient have adequate hemostasis?
3. is there any increased susceptibility to infection?
4. will drug actions or interactions cause any complications?

Question 23

what should you do if in doubt at the end of health history review

Answer 23

ask for a. physician consult - purpose is to get medical info not ask for clearance: specifically, is the medical condition stabilized? its our obligation to know th appropriate delivery considerations/guidelines based on their medical status

Question 24

what are contraindications to elective dental treatment

Answer 24

• myocardial infarction within 6 months
• stroke within 6 months
• blood pressure above 181/110
• HIV/AIDS with CD4 <50 and/or plateley count <60,000
• INR >3.5 with need for invasive treatment
• undiagnosed and/or untreated chest pain
• undiagnosed,untreated or non compliant diabetes or other endocrine diseases