Faculty Training: Clinical Skill Assessment

Workshop
Patient Health HistoryPart I

Course: Ethics and Law in Dental Hygiene

Third year DH Program, Fall semester
Cheryl Ann Davis, RDH, BS, JD, MS
cheryl.davis@ucsf.edu

The Patient Health History

Purpose: to assess a patients level of oral and
systemic wellness, past and present

When obtained in a culturally sensitive, patientcentered manner, a therapeutic relationship is

established and quality of care is improved

In conjunction with the physical/intraoral exam, the

HH provides a foundation for clinical decision
making

By the end of Part I, you will be able to

Demonstrate the proper method of gathering
information from the patient during the initial stages
of the interview, using the HH form and positive
setting

Appreciate the patient-centered interviewing

technique and its value in establishing rapport

Describe three purposes of the HH, including legal

and ethical issues involved in its documentation

Establishing the Setting and Gathering

Information
A private setting ensures client confidentiality and
communicates respect for the patient

Seat patient upright in the dental chair, introduce

yourself, use frequent eye contact, shake hands,
smile, and seat yourself eye level with the patient

Note any reluctance, physical impairments, anxiety

or nervousness on the part of the patient

Gathering Information
Inform the patient that you would like to review the
HH and ask a few questions; receive permission and
explain importance of veracity on the part of the
patient

If patient is a minor, the parent or legal guardian

should be present

Ensure the HH is completely filled out, dated, and

signed in ink; note emergency contact information

Gathering Information (cont.)

Clarify and/or validate answers to important
questions; ask, Why are you here today?

Returning patient: ask about changes in health,

medications, any recent surgeries, as well as other
changes such as occupation, address, new concerns

Document, date and initial notations regarding

changes, refer patient when prudent or required

Establishing Rapport/Patient-centered
Interviewing
Be attuned to identifying potential barriers to
effective communication, e.g., language, cultural
differences, disabilities

Seek to elicit patients emotions, personal health

agenda, and their perceptions re dental treatment

Patient-centered interviewing: open-ended

questions, active listening, feedback, and
appropriate silences

Other Purposes of the HH

Determine health status, any contraindications to care,

and need for referral or medical consultation before
treatment

ID health conditions that may affect clinical outcomes:

oral disease progression, healing, predisposition to
infection

Reduces likelihood of medical emergency/litigation

based on errors or patients preexisting conditions by
managing risks to patient and practitioner

Legal and Ethical Issues

HH is confidential and contents are protected by law

from dissemination without permission

HIPPA protects all individually identifiable

information

Keep protected information in secure areas

Consent form recommended for some services
Responsibilities to report abuse, neglect, and
infectious disease dictated by public health statutes

Faculty Training Exercise

Demonstration
10-15 minutes for group training exercise
3-4 faculty members per group
Each member assumes a role of clinician,
patient, or observer/grader

Switch roles if time permits

Summary of Key Points

Provide patient with a setting conducive to
establishing a positive rapport and therapeutic
relationship

Obtain information re a patients oral and systemic

wellness in a culturally sensitive, patient-centered
manner

Identify legal and ethical issues inherent in obtaining

and maintaining HH information

Thank you for your time

and consideration.
Questions? Feedback?

References

Darby ML, Walsh MM. Dental Hygiene Theory and Practice. 4 th

ed. St. Louis, Missouri: Saunders Elsevier; 2015.
Beemsterboer PL. Ethics and Law in Dental Hygiene. 2d ed. St.
Louis, Missouri: Saunders Elsevier: 2010.
Holmboe ES, Hawkins RE. Practical Guide to the Evaluation of
Clinical Competence. Mosby Elsevier: 2015.