Preclinic CONSENT FORMS, HEALTH HISTORY, AND VITALS

Assessment, diagnosis, planning, implementation, evaluation

What does ADPIE stand for?

Assessment

The collection and analysis of systematic and oral health data in order to identify client needs

Confirm their birthday and ask if if they need to use the restroom

What do you do when you first retrieve the patient from the waiting room?

Health insurance portability accountability act

What does HIPAA stand for?

-Hygiene new patient guidelines

-HIPAA

-Patient rights and responsibilities

-Patient general informed consent

-Consent to disclosure info

What five consent forms need to be updated

Notice of privacy practices

What does NPP stand for?

A document that tells your patients how their protected health information may be used and shared

What is the Notice of Privacy Practices (NPP)

No, it is an ongoing process; update/revised every appointment

Are the consent forms finished after one appointment?

Prior to implementing the treatment

When is consent obtained during an appointment?

Legal guardian/representative

Who signed the consent forms for under age patients

-planned procedures

-Expected successful outcomes of the procedures

-possible risk

-unanticipated outcomes

-alternatives to proposed plan of action

-Costs

What 6 things does the informed consent form inform the patient of?

Have the capacity to consent, and be able to fully understand all the information provided

What should the patient be able to do in order to consent to the document?

Age, mental capacity, language comprehension

What three things should be considered to ensure consent of the patient

Provide a signature

What does the patient do to confirm that they have read/understood/asked questions regarding the forms and confirm that all information provided is accurate and complete to their knowledge

• General health

• nutritional status

• emotional

• psychological

• social and socioeconomic factors

What does going over medical history history assess (6)

-referrals to physician or medical advice

-identify precautions or adaptations for treatment

-Risk factors impacting overall and oral health

-Baseline reference for comparison

What are the four rationales for medical history?

-name/personal info

-birth date

-Emergency contact

-Names and contacts of medical and dental providers

What are the four items of demographic information?

NO; race is a social construct

Is there any biological difference between races?

-economic stability

-Neighborhood and physical environment

-Food

-Community and social context

-education

-healthcare system

What are the six social determinants of health?

Social history information

Information such as marital status, children, occupation, cultural practices, and other beliefs

Social history information

Factor and ideology of certain diseases, may affect diet, general health

Height and weight

What is a physical characteristic that provides information for drug dosing and anesthesia and can indicate the risk for medical/dental complications?

Diabetes or other systemic diseases that impact oral health

What does disproportionate height and weight combined increase the risk for?

Medical history

The documentation of overall medical health that can identify the need for physician consultation or any contraindications for treatment

-Inform patient what/why of what they're doing

-scheduling morning appointments

-appointments short as possible

-calm/reassuring voice, tone, words, nonverbalS

-sitting at eye level with patient while having a conversation

What five things are included in the stress reduction protocol

-oral/systemic link

-dental considerations based on medication

-Dental treatment may impact a patient's systemic condition

Why is health history important to know during dental treatment?

Pharmacologic history

The list of medication's and over-the-counter drugs or products, such as herbs, vitamins, nutritional supplements, and probiotics

Confirm any past history of an allergic or adverse reaction to any products

What should the practitioner confirm when looking at the pharmacologic history?

Temperature, pulse, respiration, and blood pressure

What four things do the vital signs include

it provides a baseline or helps identify potential or undiagnosed medical conditions

What do vital signs help with?

Direct observation

Observation that begins when patient enters the healthcare setting

-review responses

-research conditions and drugs

-formulate follow up questions

What three things do we do when a patient completes a written health history questionnaire

Ask questions to clarify responses and follow up questions

What do we do when having an oral interview regarding electronic health history

-when were you diagnosed/When did this happen?

-Are you currently under the care of a physician for this condition?

-Are you taking any prescription or over-the-counter medication/herbal supplements for this condition

What are three follow-up questions that you can ask for ALL YES responses, related to conditions?

Clinic resources/building blocks document

What should you refer to for follow up questions for specific conditions?

-what condition are you taking this for?

-What is the dosage and frequency?

-When did you last take this medication/herbal supplement?

-How is the medication working for you?

What are four follow-up questions you could ask for medication?

-name of medication

-dosage/frequency

-reason taking

-pharmacologic category

-Implications on dental treatment

-Have they taken their medication and proper dosage before their appointment?

What is six things should you look for in the medication documentation/search?

-heart valve disorder

-Artificial heart valves

-Prior infective endocarditis

-congenital heart defects and repair

-Heart transplant with valve dysfunction

-prosthetics or mesh implants

-History of taking Fen-Fen or Redux

What are seven cardiac conditions that require antibiotic premed medication before dental treatment

Medical consult

What is required if a patient reports that they have been informed that they do not need to take antibiotic premed medication, but have a cardiac condition

NO

Are antibiotics recommended for total joint replacements before dental treatment?

The AHA states that it's still safe as long as the meds are taken within two hours of dental treatment; **always check with supervising dentist and they make the decision**

What happens if the patient forgot to take their antibiotic pre-medication before dental treatment

Intramuscular; intravenous

What does IM indicate for antibiotics? IV?

After 6 months

If someone has had a heart attack or stroke, how soon can you treat the patient after?

Physician consultant

If someone has had a heart attack or stroke recently, what is needed to determine recommendations regarding dental care

-heart trouble

-Coronary occlusion

-Arteriosclerosis

-Recent cardiac bypass

-Recent cardiac surgery surgery

What five things regarding vascular disease needs a possible consultant with the physician to determine recommendations regarding dental care

Hypertension

What is the term for pathologic elevation of blood pressure?

130-139/80-89

What systolic/diastolic blood pressure is in the stage one hypertension category

>=140/>=90

What systolic/diastolic blood pressure is in the stage two hypertension category

>180/>120

What systolic/diastolic blood pressure is in the hypertensive crisis category

120-129 and <80

What systolic/diastolic blood pressure is in the elevated category

<120 /<80

What is the normal blood pressure reading?

<90 / <60

What systolic/diastolic blood pressure is in the hypotension and postural hypotension category

Angina pectoris

If a patient brings nitroglycerin to an appointment, what disease do they have?

Nitroglycerin

What does the patient bring to an appointment if they have angina pectoris?

On the operatory counter; accessible

Where does the bottle of pills/spray of nitroglycerin remain throughout the appointment?

Inhaler

What would a patient bring to the appointment if they have asthma?

• Triggers

• signs and symptoms

• hospitalizations

What is three things could follow up questions include about asthma

On the operatory counter; accessible

Where does the inhaler remain during the appointment if someone has asthma?

Possible consultant with physician

What is needed to determine the kind of pacemaker a patient may need

Ultrasonic equipment may interfere with the function of it

What could happen with the pacemaker if it is unshielded?

20-30 difference in patients normal readings or < 90/< 50

What is an abnormal/concerning reading if a healthy patient has low blood pressure/hypotension

-raise chair slow

-Allow patient to sit upright for a few minutes prior to getting out of the dental chair

What two things can you do to prevent postural/orthostatic hypotension in a patient

Syncope

What is another word for fainting?

Absence of active infection (chest x-ray)

When a patient has had tuberculosis, a physician consultant is need to verify what

-rifampin

-isoniazid

-Pyrazinamide

What are three anti-tuberculosis drugs?

PMN (polymorphonuclear leukocyte or neutrophil) level and viral load prior to treating

What does a physician consult determine when someone has HIV/aids?

If lesion is in vascular or crusted stage; lesion is communicable in these stages

When should an appointment be rescheduled when someone has a fever blister/ cold sore

First trimester

Which trimester should you not treat a pregnant woman without the consult of an OBGYN?

Second trimester

Which trimester is the best time for treatment for pregnant women?

Support right side with pillow/cushion to prevent compression of vena cava

How should we physically support the pregnant woman when treating in the third trimester?

Anticoagulant therapy

What increases time for blood to clot?

Increase bleeding during invasive dental treatment

What might anticoagulant therapy result in during dental treatment?

-Explain procedures thoroughly

-Tell, show, do

-Slow pace

-Reassure throughout

-Check patient status

What are five ways to employee stress reduction techniques for people with dental anxiety?

Type one and two

What are the two types of diabetes?

Average of blood glucose over a span of three months

What does A1C level mean?

Document what they've eaten

What is an important thing to document when having a diabetes patient

Hypoglycemia diabetic ketoacidosis- coma

What can poorly control diabetes lead to?

A1C: Below 5.7%

Fasting Blood Sugar: 99 mg/dL or below

Glucose tolerance: 140 mg/dL or below

What is the normal blood glucose test? (A1C, Fasting blood sugar, glucose tolerance)

A1C: 5.7-6.4%

fasting blood sugar: 100-125 mg/dL

Glucose tolerance: 140-199 mg/dL

What does a prediabetes blood glucose test look like?

A1C: 6.5% or above

Fasting blood sugar: 126 mg/dL or above

Glucose tolerance: 200 mg/dL or above

What does a diabetes blood glucose test look like?

Infections/poor wound healing

What are people with diabetes prone to?

Glucometer

What is the device that takes blood glucose levels

Chief complaint/concern

The reason why the patient has come to the dental office

Does the patient have any:

• pain

• swelling

• bleeding

• sensitivity hot/cold/sweets

• difficulty biting/chewing

What should we ask the patient when they are telling their chief complaint?

Intensity, triggers, duration, etc

If a patient is in pain, what should the clinician attempt to assess?

Diagnose the source and resolve the problem

What is important to attempt to make sure the patient will feel that his/her needs are being met

Avoid air/water/physical contact with lesion

What should be avoided when someone has mouth sores?

-short appointment

-Frequent breaks

-mouth prop

What three things should be implemented when there is an injury to teeth/mouth/jaw

-date treatment was completed

-x-rays

-restorative?

-Cleaning?

-Experience?

What five things should we ask the patient about their history of previous dental care

-Pulse

-respirations

-temperature

-blood pressure

What are the four vital signs that need to be taken?

Too fast

What indicates a health problem regarding pulse?

-infection

-dehydration

-Stress

-Anxiety

-Thyroid disorder

-Heart conditions

-Medications

What is seven things can a pulse that is too fast indicate

People who get a lot of exercise or are athletic

When is the lower heart rate common in people?

• Equally spaced out

• not excessively strong

• no beats should be missed

What should the beats look like when taking pulse?

-regular or irregular

-strong, weak, or excessively strong/bounding

What are the descriptors when taking pulse?

Beats per minute

What is pulse recorded as?

60 to 100 bpm

What is a normal pulse recording?

>100 and <50 bpm

What is an abnormal pulse recording?

-Unlabored or labored

-Normal, shallow, or deep

What are the descriptors when taking respiration?

Rates per minute

What are respirations recorded as?