Patient Presentation and Evaluation

Question 1

What is the SOAP note format?

Answer 1

● Subjective
● Objective
● Assessment
● Plan

Question 2

What is the subjective part of SOAP?

Answer 2

● CC
● HPI
● MH/PMH/PSH/PDH
— Medications
— Allergies
— Tobacco / ETOH / Recreational Drugs
● Assessment of anxiety
● ROS

Question 3

What is the objective part of SOAP?

Answer 3

● Physical Examination (Examine the patient)
— X-Rays
— Labs

Question 4

What is the assessment part of SOAP?

Answer 4

Diagnosis

Question 5

What is the chief complaint?

Answer 5

Why is the patient there?? What do they want?

Question 6

What is HPI?

Answer 6

history of present illness

Question 7

What does the HPI (history of present illness) concern?

Answer 7

●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

Question 8

What do you find out about past dental treatments?

Answer 8

may be identified during the HPI (history of present illness)

Question 9

What does the medical history and past medical history?

Answer 9

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)

Question 10

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??

Answer 10

● The written Medical History
● The Patient Interview

Question 11

What is a medical history questionnaire?

Answer 11

■ 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

Question 12

What is the patient interview?

Answer 12

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

Question 13

What are the benefits of the patient interview?

Answer 13

■Promotes dialogue
● To gain greater insight to the magnitude of the problem(s)
● Develops rapport
● Assesses anxiety fear and phobia

Question 14

Who should conduct the patient interview?

Answer 14

the person…
● Planning to conduct the treatment
● Planning to administer the anesthetic

Question 15

Why are patient medical histoy/interview so important?

Answer 15

■ 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

Question 16

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?

Answer 16

med history/past medical history

Question 17

What allows you to place a patient in a ASA classification?

Answer 17

med history/past medical history

Question 18

What is ASA I?

Answer 18

normal, healthy patient
ex: (No systemic disease)

Question 19

What is ASA II?

Answer 19

patient with mild systemic disease which is well controlled
ex: (well controlled hypertension)

Question 20

What is ASA III?

Answer 20

patient with significant systemic disease which limits activity but not incapacitating
ex: (congestive heart failure)

Question 21

What is ASA IV?

Answer 21

patient with an incapacitating systemic disease which is a constant threat to life
ex: (unstable angina pectoris)

Question 22

What is ASA V?

Answer 22

moribund patient not expected to survive more than 24 hours
ex: (end stage kidney disease)

Question 23

What is important to find out about medications?

Answer 23

• 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

Question 24

The more categories of _____________ needed to control or optimize a particular systemic disease process, the more significant the process is

Answer 24

medication

Question 25

What is important to find out about allergies?

Answer 25

● allergies to any medicines or substances must be noted. - The provider must be able to discriminate allergic responses to medicines from side effects -Latex

Question 26

What is important to find out about social history?

Answer 26

- Tobacco - Alcohol --- Use must be quantified --- For surgery patients increased use of tobacco and alcohol may impact healing - Recreational Drugs --- Cardiovascular events

Question 27

What are options for patient fear and anxiety?

Answer 27

● Hand holding (non pharmacological methods) ● N2O/O2 ● Oral medications/Oral Pre Meds ● Intravenous medications ● General Anesthesia ● Combinations of the above

Question 28

What is ROS (review of systems)?

Answer 28

An inventory of specific body systems performed in the process of taking a history from the patient.

Question 29

What is the purpose of the ROS (review of systems)?

Answer 29

● 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

Question 30

What does the physical examination involve?

Answer 30

● Starts when the patient walks in the room ● Must include vital signs - Blood pressure - Pulse - Labs - Other measurable components (INR, BGL)

Question 31

What does the dental examination involve?

Answer 31

● Making a disposition on the current oral cavity state of repair ● Creating a problem list

Question 32

What is involved in the radiographic examination?

Answer 32

■ Panoramic radiograph ■ Periapical x-rays ■ Bitewings ■ CBCT ■ Other x-rays

Question 33

Why is the radiographic exam important?

Answer 33

● Identifies clinically important factors only observable on the radiograph ● Factors which will have impact on the extraction of the teeth. ● Placement of implants

Question 34

How do the x-rays need to look/be?

Answer 34

- Current radiographs - Diagnostic radiographs

Question 35

What should you be able to see in a radiographic exam?

Answer 35

■ 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

Question 36

What are some labs you might need?

Answer 36

*Coagulation panels --- INR *BGL --- Current level of Blood glucose *AIC --- Measure of Long term diabetic control *CBC

Question 37

What is the diagnosis for SOAP?

Answer 37

● 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

Question 38

What do medical consultations usually request to evaluate?

Answer 38

● Ability to tolerate treatment ● Medical clearance to proceed ● Modify existing medication regimens prior to the procedure - Level of anticoagulation - Insulin

Question 39

How do you adequately write a med consult?

Answer 39

- 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

Question 40

What are the steps to write a med consult?

Answer 40

- 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)

Question 41

How do you create the treatment plan?

Answer 41

* 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

Question 42

Is no treatment an option?

Answer 42

Yes * Individual risks can usually be managed * When risks are stacked that can be a problem * Don’t be a cowboy or cowgirl…refer!!!!

Question 43

What is important to know about risk assessment?

Answer 43

Know your patient * If you need more time to gather health information…take it * Assessment of systemic diseases can impact treatment * Consultations when necessary

Question 44

Is it ok to "draw your line in the sand" and not do a procedure if the risk assessment is too much?

Answer 44

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