By Diana Lamoreux, RDH, MEd
Obtaining a health history (also known as a personal health record [PHR] or medical history) is an essential part of the assessment process and is necessary to provide comprehensive dental care. Health histories guide the clinician before, during, and following treatment, helping to prevent medical emergencies and revealing treatment modifications.
Obtaining an accurate and comprehensive health history, however, poses numerous challenges to the clinician and goes far beyond patient completion of a questionnaire. Many challenges arise from a lack of patient's understanding and/or an interview query. When these two areas are consistently addressed, a more precise, complete health history will result.
Due to various reasons, such as time constraints, two critical steps in the health history assessment process are sometimes overlooked:
- Educating patients about the relevance of their health histories to their dental treatment
- Following up the questionnaire with additional questions
Omitting either or both of these steps introduces variables that affect the quality of a health history. Without patients' appreciation of the significance of their answers and clinicians' commitment to verify answers, the validity, comprehensiveness, and accuracy of any health history is in question.
Consider the following scenario of a 53-year-old male who enters a dental practice for the first time. He is accompanied by his wife of 30 years. He has a lower denture and seven remaining mobile maxillary teeth he wants extracted, as well as the construction of a maxillary denture.
He completes the extensive two-page medical history and is soon seated in one of the dentist's operatories. Shortly thereafter, the dentist enters the operatory and reviews the medical history, seeing nothing noteworthy -- Lipitor and a baby aspirin daily, as well as a history of hand arthritis.
After radiographs, a brief discussion of treatment options, and the administration of anesthetic cartridges to prepare for the extractions, the gentleman's wife enters the room with his coat, and remarks, "Thought you might need this, dear -- that you might be cold. By the way, doctor, do you think it's okay for my husband to have all these teeth pulled after his three heart attacks in the last two years?"
True story, and it is fairly obvious what could have prevented this situation. The patient evidently had little appreciation for, or understanding of, the need for the details he omitted, and probing questions did not follow the questionnaire's completion. Only a cursory review occurred.
The patient was not educated about the credibility of his history, and the clinician failed to take the time to elicit additional information from the patient before proceeding. The onus is on the clinician; patients supply answers based on their unique perspectives and backgrounds.
We know that obtaining a correct and thorough health history is in the best interest and for the protection of patients and dental staff alike.1 But patients often are not aware of the risks to themselves, and their answers are only as accurate as their perceptions. When a patient does not fully realize the value of a medical history in the dental setting, or when a patient is not queried afterwards, valuable information may be omitted, withheld or misunderstood for myriad reasons.1 Thus, the completion of the health questionnaire is merely a framework for patient education and an interview. Regardless of the type, limitations, advantages, and impersonal nature of health history forms, they cannot be expected to satisfy the overall purposes of a medical history.2
Purposes of the history
The two primary goals of a health history are prevention of medical emergencies and the identification of contraindications to treatment or precautions needed during treatment, as dental procedures can complicate or be complicated by existing conditions.2 In addition to the two primary goals, medical histories also serve the following purposes:
- Screen for previously undiagnosed conditions. Distended neck veins can be a sign of congestive heart failure -- yellow sclera a sign of liver disease
- Provide information germane to etiology and diagnosis of oral conditions
- Furnish patient medical history relative to postponement of treatment or referral of the patient
- Create a bridge between dental and medical professionals, encouraging physician consultations
- Assure the dental team will not harm
- Assist with individualization of treatment plans
- Appraise general health (ASA status) and nutritional status, helping to integrate the periodontal-systemic link
- Establish a baseline upon which future treatment and decisions are based; comparing past and present information
- Yield evidence if legal matters arise
- Integrate physical, psychological, cultural, and social concepts to guide risk assessments and treatment planning3
One of the many challenges in obtaining a reliable health history is discerning how much patients value what they report, how much they know about the worth of their health histories. This discovery takes time and commitment on the part of the clinician and the development of trust via rapport. This is a crucial step in attempting to ensure the validity of the patients' responses. Variables such as lack of rapport or trust, misunderstanding rationale and questions, impatience with medical forms, misinformation, and disregard for consequences all possibly affect outcomes.
Patients omit information from medical forms for countless reasons -- withholding details due to embarrassment or shame, fear, memory loss/aging, threatening or intimidating questions, or just mere oversight. Research has shown that patients feel uncomfortable discussing certain topics at a dental office, feeling that dentists and hygienists don't need to know everything about their health status. Add to the above that some diseases have subclinical symptoms for weeks or months, patients will answer "no" to questions that could impact care.1 The aforementioned variables and reasons can be better controlled if clinicians commit to educating the patient, thus enhancing the quality of health histories.
A variety of health history forms are currently available -- customized, online, generic, commercially available, or through the American Dental Associaton. The newest trend in dentistry is requesting that patients complete (or review) their histories online, accompanied by instructive dictates, prior to appointments. This serves multiple purposes with the educational aspect being reinforced at their scheduled time.
From the very first contact with office personnel, whether it is before or after questionnaire completion, patients should be advised about the relevance of their medical background to their future dental treatment, as well as the significance of their answers to individualized treatment planning. It is ideal if dialogue can occur prior to questionnaire completion but logistics often denies that opportunity. Thus, it becomes a bigger challenge after the fact to ascertain how much a patient understood or valued the survey, rather than being proactive.
It is the clinician's unique opportunity to relay why the information requested is essential before individualized treatment can commence, discussing the interrelationship between oral conditions and general health, how overall health influences the response to treatment, and that every individual's health is in flux.
Usually through education in a conducive, private, and respectful environment, patients come to view the clinician as competent, with rapport and trust consequently developing. Nevertheless, establishing rapport and trust can be a nebulous intangible. Some clinicians struggle to develop it; others just have the gift. In an environment where rapport has been created, trust instilled, and the patient values the relevance and worth of their medical history, the stage has been set for a productive interview and more binding results.
In a setting where the patient does not respect the clinician or does not perceive the applicability of their answers to dental treatment, unreliable outcomes will result.
As with many of our daily duties, it can be tempting to shirk responsibility -- be less vested in an area of treatment. Yet, not giving our full attention to patient health histories can cause a medical emergency, perhaps even cost a life. Ascertaining that questionnaire inquiries are fully understood and validating that the questionnaire is complete is the benchmark of the interview process and offers assurance that any given health history is "reasonably accurate."4 Dedicating the time to perceive each history as a thought-provoking investigation -- a type of puzzle, a puzzle where pieces need to fit, and pieces are not mising -- can add an enjoyable element to patient care.
Questions on health histories incorporate patients' medical backgrounds, age, language and cultural barriers, medical and dental IQs, and usually include system-oriented, disease-oriented, symptom-oriented, and culture-oriented categories.
When the survey answers are critically analyzed by clinicians, additional relevant questions can be posed, patients can be cued, questions can be rephrased, and answers clarified. Cues naturally prompt patients, stimulate memory, causing patients to expand on the responses and often reveal important details. The rapport and trust that was developed during the educational dialogue is supported during the interview. The clinician can then assess whether the questions were understood, if any critical information was misconstrued, omitted, or forgotten.
All positive responses should be systematically pursued, especially key areas pertaining to questions regarding heart/
cardiovascular disease, lung, liver/hepatitis, kidney conditions, chemotherapy or bisphosphonate treatment, long-term steroid use, some shunts, cardiac valves, artificial joints, tuberculosis, and HIV+/AIDS. Once extensive review of the health history is conducted, an ASA (American Society of Anesthesiologists) classification can be assigned as a baseline and for future reference.
The process of obtaining good histories, so critical to comprehensive dental care, is fraught with challenges and variables out of our control. It is anyone's guess how accurate and complete any given history is. If we are consistently conscientious about raising awareness and interviewing, however, fewer doubts about patients' histories should result. Familiarity with past problems will prepare professionals for future possibilities. RDH
1. McDaniel TF, Miller D, Jones R, Davis M. "Assessing patient willingness to reveal health history information," JADA 1995;126;375-379.
2. Wilkins EM. Clinical Practice of the Dental Hygienist, 10TH Edition, pages 114, 116, 360 (Table 21-1), Philadelphia: Wolters-Kluwer, 2009.
3. Burkhalter N. "NURS 3315: Health Assessment" Texas A & M International University, School of Nursing, 2004.
4. Morrissey J. "Obtaining a reasonably accurate health history" PlastSurgNurs 1994 Spring; 14(1):27-30. PubMed.gov. US National Library of Medicine, National Institutes of Health.
5. Tyler MT, Lozada-Nur F, Glick M. "Clinician's Guide to Treatment of Medically Complex Dental Patients," Baltimore: The American Academy of Oral Medicine, 2001.
DIANA J. LAMOREUX, RDH, BS, MEd, graduated from Ohio State University in 1972, practiced dental hygiene for over 30 years, was a part-time clinical instructor in the Cleveland area since 1981 and recently retired in December 2011.
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