Hands On

Safety questions on the health history

Background

Clinical patient records are used to assess the quality of care, evaluate therapy outcomes, and manage patient care. These are now classified as legal documents and may be subpoenaed in court cases. Because of the importance of these records, they should be thorough and regularly updated to reflect the most current information. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) classifies patient records as protected health information (PHI). This classification requires

Health History Safety Discussion

While taking the health history, the clinician should focus on providing treatment for the patient. The environment and the process should be made as comfortable as possible so that the patient feels he or she can completely and informatively give accurate answers to questions.

Personal matters such as domestic violence can be approached by allowing the patient to complete the history in a setting that permits interaction but is not anxiety inducing. For example, the office may have posters or

Interventions in Domestic Violence

Questions about family violence on history forms provide clinicians with the opportunity to evaluate abuse externally and internally. To do this well requires that the practitioner be aware of the various aspects of domestic violence and therefore able to recognize signs of abuse and assist patients accordingly.

Most physical injuries related to abuse result in damage to the head and neck areas. These include chipped or cracked teeth, poor oral hygiene, black eyes, bruises, or fingernail marks

Discussion

It’s important to take a careful health history for all dental patients. The information provided may reveal domestic violence or other issues that must be reported so that the patient’s safety is ensured.