pc w12 (med hist & extraoral assess)

PIPEDA (effective Jan 2004 + 10 principles)

• personal info protection and electronic documents act

• canadian law relating to data privacy

• govern how priv-sector orgs collect, use & disclose personal info in the course of commercial business

1. Accountability

2. Identify purpose

3. Consent

4. Limiting collection

5. Limiting use

6. Accuracy

7. Safeguards

8. Openness

9. Individual access

10. Challenging compliance

1. Accountability

• Responsible for information, its protection, accuracy, and control

• Designate an individual to be accountable for the office/organization

2. Identifying Purpose

• Identify purpose before or while the information is collected

3. Consent

• Individual’s knowledge

• Consent to collect, use, or disclose

4. Limiting Collecting

• Only info necessary

• Collected fairly & lawfully

5. Limited Use

• Use only for the purpose collected

• Request consent

• Legal exceptions

6. Accuracy

• Accurate

• Complete

• Up-to-date

7. Safeguards

• Approp to the sensitivity of info

• Phys measures (locked cabinet)

• Technology tools (passwords, firewalls)

• Organizational controls (staff train, confidentiality agreements

8. Openness

• Disclose info/policy practices

• Disclose info to person it involves

9. Indiv Access

• Patient access

• ability to challenge accuracy & completedness

• Amend as approp.

10. Challenging Compliance

• complaint to designated indiv in org

• Contravention of PIPEDA (not fulfilling oblig of regulation)

• crim offense

Purpose of Health History

• provide foundation for all clinical decisions

Determs

• health status

• contraindications to care

• necessity of a physician consultation

DH care

• complicate existing health conds?

• existing health conds can influence the clinical outcomes?

• health his must be updated start of each appt.

Why a health history?

• Baseline information

• Overall assessment

• Identifies risk factors

• Assist in diagnosis

• Identify need for referrals

• Maintain legal documentation

Health History Assessment

• direct observation/extraoral assessment

• overall appearance of client

- emotional physical gait, skin color, eyes, dress

- client response

- need of assistive device (cane, hearing aid)

- independence of patient

- any impairments (medication, alcohol)

- use of eye contact, non verbal communic, body lang

Written Health History Questionnaire

• constitutes a legal doc

• past & present info

includes…

1. personal

• name, address, phone#,

• birthday, gender, marital stat

• cultural practices related to health/disease

• referral source, types of insurance, emergency contact

• previous dentist, current physician w address, phone #

2. social

• financial status, recreate activities, prim lang

• cultural role/influences, community resources

• environ risk factors, social relationships

3. dental

• prev dental treatments/complications/neg experiences

• current symptoms & concerns

• bleeding gum/tooth ache/ swelling/appearance

• current oral habits (brux, thumbsuck, cheekbite)

• OH self care habits, practices prods, freq & duration of use

• Fluoride hist

• water toothpaste rinses drops

• diet

• OH beliefs

4. med health status

• docs the clients overall health

• meds, risk factors for disease, allergies/rxns

• contraindictions to care, undiagnosed conds

• need for phys consult prior to OH care

Chief Complaint

• client’s prim reason for appt

• address no matter how minor

• write in client’s words (use ““)

Interview technique (3 phases)

1. Orientation Phase

• intro, get acquainted

• ask appt reason, identify resources required

• explain need to ask additional q to ensure optimal care

• foster trust & ensure confidentiality

2. Working phase

• clarify responses on the questionaire (ask non yes/no questions)

• ex: tell me abt chest pain you reported

• they discuss it (use proper listening skills)

• back-channeling (uhuh, all right)

3. Termination Phase

• give client cluse interview coming to an end

• ex: we’ll be finished in one min

Questionnaire (any yes answers must be elaborated)

• 3 types of questions

1. System-Oriented

• includes direct q/topics indicated if they have had a disease

• ex: CV sys

2. Disease-Oriented

• typical q “do you/ have you had any of the following disease/probs

• ex: asthma, diabetes, rheumatic fever

• follow up questions determine dates, severity, & outcomes

3. Symptom-Oriented

• suspicion of a cond - may suggest follow up with MD

• are you often thristy? do you often experience dry mouth (sus of diabetes)

Health History

• review & update each appt

• always use non-erasable blue/black pen

• carefully written + legible

• mistakes crossed/dated/initialed/signed

• no correction fluid or made illegible

* med alerts noted on top of each page in red

*red to cross out

Drug Ref Book

• (CPS) compendium of pharmaceuticals & specialties

• states info abt specif durgs & drug interacts

CDHA Online

• free to members

• good info resource

before care, DH docs medications client has taken

(PDR) physician desk references

• essential guide of DH practice

• provide valuable info abt prescript drug prods

CONT

Physician Consultation

Medical consultations are rec for…

• a cond that may need prophylactic

• antibiot meds uncertainty

• sus of undiagnosed/uncontrolled cond

• abnorm vital

Legal, Ethical

Extraoral Assessment Exam

• includes overall appraisal of client’s gen characteristics

• thorough eval of client head, face, neck area

• esp skin & assoc lymph nodes (normal vs abnorm)

Observation

act of viewing & watching the client to collect data to detect variations from normal & potential disease states

• Client movement –gait, posture

• Speech

• Respiration

• Body structure- skeletal discrepancies

• Symmetry

• Skin and mucous membrane colour, texture, consistency, contour and form

• Client knowledge, attitude and behavior

Lymph Nodes

Approx 63% ppll w/ oral cancer have palpable enlarged nodes

Large, fixed, non tender nodes

• Possible malignancy

Small, freely moveable tender notes

• Possible infect