By Diane Paz, RDH, MEd, DBH
Funny how something can happen and suddenly, you now must report it on every health history going forward. It can be something as simple as a new medication or something as serious as a heart condition. One day you are fine, and the next, your ASA (American Society of Anesthesiologists) status changes.
As a dental hygienist, we are trained to review the patient’s medical history at every appointment. If you treated a patient with scaling and root planing six weeks ago, do you take time to review the health history thoroughly at the reevaluation appointment, or do you take it for granted that things are the same? If you do the latter, you could potentially suffer an office medical emergency or possible litigation.
Take, for example, the case of 43-year-old Mrs. Jones. Three months ago, she presented for her routine periodontal maintenance appointment. Her health history was unremarkable at that time. She had a history of elevated cholesterol and high triglycerides. She reported that she takes 20 mg of Lipitor (atorvastatin) and 145 mg of TriCor (fenofibrate).
What we didn’t know was that three weeks ago Mrs. Jones suffered a fall and was treated for a blood clot while in the hospital. She is now taking warfarin. When she presented for her appointment, she was asked the usual perfunctory question of whether there was any change in her health.
Mrs. Jones, not seeing the rationale for disclosing something that clearly had nothing to do with having her teeth scaled, failed to mention that she had fallen, had a blood clot, and was now taking a potent blood thinner. The hygienist proceeded to rescale areas that needed re-treatment and was clearly perplexed by the amount of hemorrhage. She thought that perhaps it was residual infection so she initiated local anesthesia and localized SRP in an effort to re-treat the area.
Fortunately, Mrs. Jones was able to tolerate the treatment, but without a current international normalized ratio (INR), both she and the hygienist were at risk for potential problems. So, what should the dialog have been? Perhaps a better approach to every patient would be to change the discussion so that it includes more open-ended questions: “Mrs. Jones, since we treated you last, what have you visited your medical doctor for?"or Mrs. Jones, tell me about any new medications you have been taking since we last saw you.”
Open-ended questions allow your patient to share more than just a “yes” or “no” response. This technique is designed to engage your patient rather than having him or her simply sit in your chair.
Let’s look at another example. John Smith is a healthy-looking 13-year-old teenager. He has the typical oral hygiene a hygienist might expect of a young man, but his plaque score is only 20%. He reports that he brushes twice a day but the bleeding on probing clearly tells another story. His health history is unremarkable. His mother seems a bit on edge, but she diligently fills out the paperwork and hands it to the receptionist. Since the patient is 13, the mother chooses to stay in the reception area. As the hygienist, you ask the patient if he has any changes in his health since you last saw him. He responds that he is fine.
What the hygienist did not know was that he was being evaluated for a blood dyscrasia, possibly leukemia. His mother has not shared the details with him yet so as not to cause undue stress until a diagnosis is confirmed. So, what might a better dialogue have sounded like? An open-ended question such as: What have you seen the doctor for since I last saw you? or Have you had a doctor visit since you were here last? A “yes” to either by the minor would suggest that you have a conversation with the parent or guardian for more details. Whether the mother was present or not, you should always review the health history with a parent or guardian of a minor.
The health history is only as good as the information gleaned from it. It is up to the dental hygienist to critically evaluate each question and not merely glance at it, considering it just one more thing to cover during the 45-minute appointment time allotted.
A thorough health history should always include open-ended questions. Questions requiring a “yes” or “no” will yield just that. Well-written questions will require more thought and in-depth answers. Consider the wording of a typical health history question asking for the date of the patient’s last medical exam. Does it provide any useful information? A better-worded question might be: “Since your last visit with us, have you been seen by your medical doctor or been treated by any medical professional?” In some cases, patients who visited their physician’s assistant (PA) do not believe that it warrants disclosure. Also, asking “since your last visit with us” requires more for an answer than “I think I saw my MD last year but I don’t remember why.”
A health history is like an SRP appointment. If you just scratch the surface of the tooth, you get some information about the patient’s condition, but if you truly evaluate all of the data during your assessments, the picture becomes clearer and you are in a better position to provide optimal care.
Take time to read each question on the health history and encourage your patient to share details with you. Will you encounter patients who don’t believe it is important to let you know certain personal pieces of their health history? Absolutely. But when you present yourself as a professional, knowledgeable, and compassionate caregiver, you are in a better position to advocate for both your patient and the dental hygiene profession. RDH
Diane Paz, RDH, MEd, DBH, earned her CDA and RDH from Phoenix College, and her BSDH, expanded functions, and master’s degree in education from Northern Arizona University. She earned her doctorate degree in behavioral health from Arizona State University. Dr. Paz is a former associate clinical professor at Northern Arizona University and currently teaches at Carrington College and Rio Salado College in Arizona. She can be reached at [email protected].