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Web Exclusive | March 5, 2009
The set-up Oral healthcare providers learn about the importance of conducting a thorough health history during the first week of professional education. Dental students are told they must determine which past or current medical issues exist, and whether there are any accompanying signs and symptoms, before providing dental care.
Time for an update When establishing a practice, clinicians typically model their health history questionnaire after the one they learned about in dental school. New graduates joining an existing practice typically ‘buy in to’ the health history form and format that is already established, but, these days that may be a mistake. As society has become more complex, with changing social issues, and as the understanding of disease etiologies has progressed, it is incumbent upon the clinician to update the medical history assessment to accommodate these changes. By doing so, medical emergencies can be prevented, and patient care optimized. The goal When it comes to updating your health history assessment you should consider three components, and health/oral health literacy should be first on the list. The questionnaire will not provide useful information if the patient completing the form doesn’t understand it. Second, make sure you include questions that have assumed new relevance, and delete items that are no longer relevant. And finally, determine which health screening tests you can offer in the dental setting. Why health/oral health literacy matters
Oral health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate oral health decisions, according to the American Dental Association. The ADA has made oral health literacy a priority, passing three resolutions at its October 2008 annual session that build on its work to promote ‘clear, accurate and effective communication’ in the profession. The ADA has asserted that limited oral health literacy is a potential barrier to the effective prevention, diagnosis and treatment of oral disease1. In emphasizing the importance of the concept of health literacy, the American Medical Association has asserted that poor health literacy is a stronger predictor of a person’s health than age, income, unemployment status, education level and race2. Individuals lacking basic health literacy may not fully comprehend the health history form that your practice provides. They may not be aware of this lack of understanding, or they may be too embarrassed to acknowledge it. Even if the questionnaire is completed to the best of their ability, the information provided may be inaccurate or incomplete. It is tempting to believe the middle- or upper-middle class individuals who comprise the patient load of a traditional private practice dental setting would not have such literacy issues, but they often do, which can compromise the accuracy of the information you receive. Remember, reading abilities are typically three to five grade levels below the last year of school the patient completed. Therefore, your patients with a high school diploma typically read at a seventh or eighth grade level. Approximately half of Medicare/Medicaid recipients read below the fifth grade level4. Keep it simple Currently, the literature suggests that information written at a sixth to eighth grade level will be accessible to most Americans5. It is best if the material is written in short sentences in the active voice, using words with fewer than three syllables and simple grammar. Making the material look easy to read is as important as the actual reading level. Larger fonts and liberal amounts of white space and graphics allow the reader to be more comfortable with the content. Illustrations can provide essential information in non-verbal ways. Keeping this information in mind when the health history form is modified can increase the accuracy of the information provided. The combination of a written and interview format will be more likely to reveal discrepancies in understanding than an exclusively written format. What should be included Updating the content of the questionnaire will involve more additions than deletions. The deletions mostly refer to changes from the American Heart Association. Because heart murmur and history of rheumatic fever do not currently carry recommendations for antibiotic premedication6, it is no longer pertinent to include these. Inclusion of some newer items may require ‘out of the box’ thinking on the part of the practitioner who may wonder if these items are more appropriately placed in the medical setting. The issue is not that the dentist/dental hygienist is expected to take on the role of the physician. But rather the emphasis is on discovering information that suggests a medical referral. There are two pertinent issues to consider: 1) Patients visit the dental office more frequently than the medical setting; 2) By adding a few questions and being part of the ensuing discussion, the patient’s quality of life can be improved or even saved. Click here for questionnaire additions you might want to consider; remember it is not an all inclusive list. Screening tests It’s also important to think beyond the questionnaire and to add simple screening tests to every appointment. Primary healthcare assessment in the dental practice can be expanded, resulting in improved healthcare outcomes for patients7. The goal is not to transform the oral healthcare setting into the patient’s medical home, but rather to detect conditions that may otherwise go undiagnosed. The appreciation of such efforts is likely to elevate the dental practice in the eyes of the patient-consumer, leading to loyalty and increased word-of-mouth referrals. It doesn’t stop here The health questionnaire needs to be a continually changing component of your practice. In addition to preventing adverse events in the dental setting, the medical health questionnaire can be used as a starting point for a dialogue with patients to screen for medical conditions they may not be aware of and to inform patients of new medical information that may pertain to them8.
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