Create a safe, trustworthy environment for patients who have been abused
BY Chris Marie Harris, RDH, BS
The practice of medical record keeping dates back to the fifth century B.C., when Hippocrates and his followers used medical records to investigate the causes of diseases and to track their courses.1 It was not until the 20th century, however, that clinical records were routinely used as tools to assess the quality of medical health care, evaluate the outcomes of therapy, or manage patient care. Today, health histories are legal documents that are a part of the patients' treatment records. These documents can be subpoenaed in court cases, including malpractice suits and domestic violence cases.
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Members of both the medical and dental professions should be required to update each patient's health history during each visit, treating the process as a classified interview.2 Most current medical and dental health history forms are not designed to include pertinent questions about patient safety, but these questions are necessary to help health-care providers understand their patients and provide the best possible treatment.
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), these records are considered to be Protected Health Information (PHI). As a result, medical and dental practices must take federally mandated steps to protect the privacy of the information within these documents.2 In addition to being the legal record, the written documentation of the health history can reveal medical conditions that patients otherwise might not think about revealing to a medical or dental health-care provider. The health history also keeps patients' medical and dental health histories consistent, bridging the communicative gaps between medical and dental professionals.
A good strategy for taking a medical and dental history is to focus on treating each patient, rather than on the condition that s/he may not want to report. Focusing on each patient involves ensuring that both the environment and the interview process are comfortable. The environment of the office influences how comfortable patients feel while filling out the forms and thereby how complete and informative their answers will be.
Discussing domestic violence
To help patients feel comfortable discussing personal matters, allow them to complete the medical and dental history in an environment that allows for interaction but does not cause anxiety. For example, offices that exhibit nonverbal cues, such as literature or posters about family violence in the reception area, will appear to exhibit empathy toward patients who experience family violence.
To make the interview process more comfortable, ensure that it does not feel like an interrogation. If the tone of the form is of a safe and nonjudgmental nature, patients are more likely to complete the form and feel at ease while talking with health-care provider(s). Patients may even feel relaxed in seeking advice and resources from the health-care provider(s). Here are some examples of questions about safety issues:
• Have you ever been hit, hurt, threatened, or abused?
• Have you experienced a significant injury during the past year?
• Are you now or have you ever been emotionally or physically abused by either a family member or someone close to you?
• Have you had an injury to your face, head, neck, or jaw?
Patients may ask themselves, "Why do I need to share my medical history with my dentist?" The answer is that the history provided by the patient, coupled with the results of clinical examinations, will help the oral health-care provider(s) recommend the best treatment approach for the patient. Not to mention, according to the U.S. Surgeon General's Report, oral health is the gateway to overall health.3 Many diseases can have significant effects on the health of the mouth and teeth, and researchers continue to link oral health issues with systemic health issues; for instance, diabetes can increase the risk of periodontal disease.4
Health history forms
Figure 1: Comprehensive Medical/Dental History Form
Have you experienced any significant injury during the past year?
Are you now being or have you ever been emotionally or
I certify that I have updated my dentist and/or dental hygienist of any and all specific changes in my medical health history. I will not hold my dentist or any of his/her staff responsible for any errors caused by omissions that I may have not mentioned upon the update of my health.
Patient or parent/guardian signature: __________________________
Dentist/dental hygienist signature: _____________________________
Changes: Yes No
The information on the medical and dental history forms can also provide information about the medications that patients are taking. Prescription information may be vital to a patient's health, especially if an emergency should arise. Some medications cause xerostomia, which can lead to the risk of increased cavities. A patient's other medications may require the medical and dental health-care providers to change anesthesia for a procedure. There may also be drug interactions between medications being taken by a patient and the prescription drug(s) that the health-care provider may want to prescribe. When patients start to realize that the information given on the medical and dental history form serves as important documentation, they may be less likely to resist providing information and more likely to feel safe in providing details about their medical conditions.
Including more questions about abuse on medical and dental history forms would provide medical and oral health-care providers with the opportunity to assess abuse both externally and internally. Requiring these questions on health history forms would require health-care providers to become more knowledgeable about family violence. As a result, more health-care providers would be able to recognize the signs of abuse and assist patients who have been abused.
Research has indicated that most physical injuries resulting from abuse are found in the head and neck regions. For example, oral health-care providers may observe physical injuries such as chipped or cracked teeth; poor oral hygiene; a broken jaw; a black eye; a broken nose; bruises on the earlobes or chin; and/or fingernail marks on the neck, upper arms, or wrists.5 Many studies have confirmed that head, face, and neck injuries occur in more than one half of abuse cases in children.6 In a study involving 218 female victims of domestic violence, 70% of injuries were bruises, and 68% were in the facial region.7 Cases of abuse in the elderly most frequently involve bruises, welts, broken dentures, fractured and missing teeth, as well as abrasions and lacerations.8
Role in intervention
Given that dental health-care providers routinely assess patients' head, neck, and facial regions, they play a vital role in domestic violence intervention. In 1998, a national survey revealed that 9.2 to 16.7% of women with abuse-related injuries requiring medical attention had visited dentists.9 At least 46 state laws mandate health-care providers to report abuse in all patients. Medical and dental history forms should support our efforts to be aware of and respond to patients' health.
Offering both electronic and hard-copy forms can help to alleviate patients' frustration with filling out the forms and can enable them to provide more comprehensive health histories. Figure 1 is an example of the end of a comprehensive medical and dental health history form where modifications include safety questions about abuse as well as referral information for patients who are being abused.10
Sometimes, the information that a patient provides will require communication or a referral between the dentist and the patient's physician. The National Domestic Violence Hotline [(800) 799-7233] can be shared too. This type of communication can help to promote trustworthy relationships between doctors and patients. Including questions about safety on medical and dental forms educates patients about health-care professionals' willingness to screen for abuse. It also acknowledges that abuse is a public-health issue. By screening patients for abuse and offering referral services for patients who have experienced abuse, health-care providers in both the medical and dental fields can create a trustworthy, safe environment for their patients. RDH
Chris Marie Harris, RDH, BS, has a certificate in dental hygiene from Howard University and a bachelor's degree from Thomas Edison State College. She is currently completing her master's degree at Forsyth School of Dental Hygiene. She has been practicing in the Washington, D.C., area since 1990. She has published articles on domestic violence for several publications. She can be contacted at [email protected].
1. Reiser SJ. The clinical record in medicine, part 1: Learning from cases. Ann Intern Med 114 (1991): 902-907.
2. Health Insurance Portability and Accountability Act of 1996. U.S. Department of Health and Human Services. http://www.hhs.gov
3. Advancing Oral Health in America: HRSA 2010. http://www.hrsa.gov/publichealth
4. American Heart Association. 2012. http://www.my.americanheart.org.
5. Office for Victims of Crime. Office of Justice Programs. U.S. Department of Justice. 2004. http://www.ojp.usdoj.gov
6. Kellogg N. The Committee on Child Abuse and Neglect. "Oral and Dental Aspects of Child Abuse and Neglect: Joint Statement of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry." Pediatrics (1999): 348-350.
7. Berrios DC, Grady D. "Domestic Violence: Risk Factors and Outcomes." Western Journal of Medicine 155 (1991): 133-135.
8. Littel K. "Family Violence: An Intervention Model for Dental Professionals." Office for Victims of Crime (2004). http://www.ovc.gov/publications/bulletins/dentalproviders/welcome.html
9. Tjaden P, Thoennes N. "Prevalence, Incidence, and Consequences of Violence Against Women: Findings from the National Violence Against Women Survey." National Institute of Justice: Centers for Disease Control and Prevention (1998). http://www.ncjr.gov/../172
10. "Medical Dental History Form." HealthPartners. http://www.healthpartners.com/files/34768.pdf
11. Govoni M, Leeuw W. "Designing a Comprehensive Health History." Dentalcare (2005). http://www.dentalcare.com/media/en-us/education/..ce76.pdf