ITC PART 3

medical, dental, social history taking

procedure before a patient appointment begins

• introduce yourself by name and role

• confirm patient identity - 2 out of 3 (name/ address/ DOB)

• ensure correct patient records

• check medical history for any changes

• confirm reason for attendance

• if procedure is to be undertaken, ensure there is a signed treatment plan, also confirm the site of the procedure

• ensure full patient consent is achieved

• relevant radiographs should be made available

what is the acronym used for asking a patient about their pain

SOCRATES

outline SOCRATES

• SITE - where is the pain located?

• ONSET - when did the pain begin? is it improving or worsening?

• CHARACTER - sharp stabbing/ ache/ dull? (nature of pain)

• RADIATION - has the pain spread to other areas?

• ASSOCIATIONS - other associated symptoms e.g. fever

• TIME - when does the pain occur? is it constant or intermittent?

• ELICITING/ ALLEVIATING FACTORS - what brings on the pain/ relieves it?

• SEVERITY - on a scale of 1-10

tips whilst talking to patients and asking them questions

• use laymen’s terms

• ask open ended questions

• consider secondary questions to a question that gives a response e.g. have you had these symptoms before? what treatment was offered to you? was that treatment successful?

CCDH adult assessment form

CCDH new paediatric patient assessment form

examples of questions to ask when taking a past dental history

• when was their last dental visit?

• is the patient a regular or irregular attender? why so?

• what treatments have they received in the past? when?

• complications associated with previous treatments?

• does the patient have dental anxiety?

• allergies? e.g. latex, colophony (fluoride varnish)