The document discusses the importance of obtaining and updating a patient's medical history at each dental visit. It describes the components of a medical history form, including patient information, medical conditions, medications, and allergies. Maintaining confidentiality of the medical history is important. The document also covers assessing the patient's American Society of Anesthesiologists physical classification and researching their medications using references like the Physician's Desk Reference.

1. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Medical History
Chapter 2

2. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Objectives
• Upon completion of this chapter, you will
be able to:
– Name the basic components of a dental
patient’s medical history
– Name the basic components of a dental
patient’s dental history
– List the ASA classifications that are pertinent
to the care of a dental patient
2

3. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Objectives (cont’d.)
– Explain why confidentiality should be
maintained on all dental patient information
– Explain the importance of having an accurate,
updated medical history for the dental patient
– Demonstrate the technique for completing
and updating the health history
– Demonstrate the technique for utilizing the
Physician’s Desk Reference (PDR)
3

4. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Medical History Format
• Medical history form components:
– Patient’s general information (name, age,
address, emergency contact)
– Patient’s primary care physician
– Detailed section on patient’s medical history
• Past and present medical conditions
• Current medications, allergies, and past medical
surgeries
– Dental history
4

5. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Medical History Format (cont’d.)
• Medical history section:
– List each condition’s common name for ease
of patient understanding
– Yes/No format with room for auxiliary follow-
up questions
– Available in different languages to
accommodate non-English speaking patients
5

6. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Completing the Medical History
• Dental auxiliary or receptionist should be
available to answer patient questions
– Should question the patient about any positive
results or conflicting answers
– Should maintain a professional and caring
manner when questioning the patient
6

7. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Completing the Medical History
(cont’d.)
• Medical conditions should be reported to
the dentist, particularly any that may result
in an emergency
7

8. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Confidentiality of the Medical
History
• Information on the medical history is
confidential and should only be available
to authorized users with patient consent
• HIPAA (1996) law established rules for the
protection of PHI (Protected Health
Information)
8

9. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Updating the Health History
• Health history should be updated at every
patient visit
9

10. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Assessment of the Dental Patient
• Dental auxiliary should assess patient:
– Review the medical history
– Note likely side effects of any prescribed
medications
• Place patient into physical classification
based on the American Society of
Anesthesiologists (ASA)
– Dental team only deals with first four
classifications
10

11. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
ASA Physical Status Classifications
Table 2-1: ASA Physical Status Classifications
11

12. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Using Drug Reference Manuals
• Dental auxiliary should research and
record information about the patient’s
prescribed medications
– Note side effects, particularly those that have
dental complications
12

13. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Using Drug Reference Manuals
(cont’d.)
– Physician’s Desk Reference (PDR) is one of
many resources to research drug information
– Important to have up-to-date resource as
drugs change at a rapid pace
13

14. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Using the Physician’s Desk
Reference (PDR)
• Compiled annually and contains
information about a variety of medications
• Identification section provides pictures of a
wide variety of medications, so auxiliary
can visually identify the medication
• Auxiliary should be familiar with the
contents of the drug reference source
14

15. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Using the Physician’s Desk
Reference (PDR) (cont’d.)
• Many other drug resources besides the
PDR:
– Delmar Healthcare Drug Handbook
• Also updated annually
– Drug references for specialties, such as
Delmar’s Mini Guide to Psychiatric Drugs
– Electronic versions of drug reference manuals
• CD/DVD or Web sites
15

16. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Using the Physician’s Desk
Reference (PDR) (cont’d.)
• Auxiliary should:
– Know as much as possible about the patient
to assist the dentist
– Be familiar with and utilize the drug reference
resource regularly
– Make certain the resource is up-to-date since
medications change rapidly
16

17. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned,
copied, duplicated, or posted to a publicly accessible website, in whole or in part.
Summary
• Dental staff have little knowledge of the
medical problems a patient may have
• The medical history informs the staff of:
– Medical problems for which to be prepared
– Drugs or treatments to avoid
• With this information, the dental team can
better prevent serious office emergencies
17