PME ch 15: analysis of info with clinical applications

”has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?” “name of physician or dentist making the recommendation and phone number.”

-resolve practitioner recommendations and assist client in understanding recommendations

-may result in previous recommendation being rescinded, based on current guidlines

-ex: joint replacement: was for 2 years; 6 months; may not be needed unless underlying conditons

“do you have any disease, condition, or problem not listed above that you think I should know about?” “please explain.”

client’s response would require:

-analysis of impact on planned procedures

-effects of medications associated with newly reported condition

-high cholesterol, follow up questions (1999)

client/legal guardian signatures and dates

-reminder of importance of disclosing all health issues prior to treatment

-acknowledgement of accuracy and truthfulness

-disclaimer of dentist’s responsibility for errors due to omission of info in HH

-never treat a stranger (difference between stranger and NP)

-signatures

• client if older than 18

• legal guardians if client is under 18

-date

• follow up dates when changes are made

purpose of “for completion by dentist” section

-analysis of health history info

-clinical and management decisions based on health history

-protection against lawsuits

types of info included in “for completion by dentist” section

-verification of info reported by client

-medical consultations completed

-consideration of pertinent laboratory data

-relationship of info to planned oral procedures

health insurance portability and accountability act (HIPAA)

-established in 1996

-increased accountability and affordability of health insurance

-ability to keep insurance after job loss

-privacy of electronically transmitted health info since april 14, 2003

-protection of personal health info

-availability of written policies to clients

-administrative, physical, and technical safeguards (personal need to know just what they need to do their job)

privacy behaviors allowed by HIPAA

-call out client name to be seated for treatment

-have clients sign in

-place chart markers related to safety alerts inside of chart (ex: allergies)

privacy behaviors required by HIPAA

-ensure privacy when discussing client treatment in office

-store client dental charts away from public view

requirements of dental office with HIPAA

-learn HIPAA requirements

-appoint a compliance officer

-receive complaints

-develop office policies on security and privacy protocols

-provide written policies to clients

-secure client signature to verify receipt of policies

-develop employee training sessions

-establish discipline protocol for violations

-prepare privacy agreements with business partners

-post written notice of privacy assurance in public areas

-provide clients the right to:

• access personal health info

• identify errors

• request changes

-develop self-audit procedure to monitor compliance

-document training sessions and personnel trained

suggested protocol for emergency management

-written emergency plan

-BLS certification for all staff

-regular CPR training

-periodic office emergency drills

-protocols for unconsciousness, cardiac arrest

-emergency kit and knowledge of how to use it

-administration of oxygen

-documentation of emergency events in client records

-each member has responsibilities

• DDS injectable drugs

• front desk call 911

• assistant gets oxygen/emergency kit

• hygienist monitor and record vitals every 5 minutes