Patient assessment and record keeping
Patient assessment and record keeping
This information is primarily aimed at dentists but is also of relevance to other health care providers.
When a patient presents with an acute dental problem, a basic assessment that enables the management of the patient’s immediate needs is sufficient. This should always include the following:
- Collection or review and updating of the patient’s medical history, including any pain relief medication they have already taken to assess for the possibility of overdose (see Analgesia), and any allergies or previous reactions to medications such as penicillin or chlorhexidine.
- Clinical assessment tailored towards diagnosing the presenting problem.
- Examination of the oral mucosal tissue for any suspicious lesions.
- Encouraging irregular attenders to return for a full oral health assessment and subsequent regular review.
For more details refer to the SDCEP Oral Health Assessment and Review guidance.
Although signs and symptoms that help initiate an assessment of the patient’s condition are included in this guidance, some patients with special care needs may not exhibit these classic signs or symptoms. In such patients, oral health problems might be indicated by changes in behaviour, such as hitting the head with a fist, banging the head, refusal to eat, biting, chewing clothing, excessive drooling or an uncharacteristic inability to stay still.
Good record keeping underpins the provision of quality patient care.17 Increasingly, the care of patients is shared among dental team members and between other professionals. Therefore, it is important to ensure that all relevant information is available to facilitate the provision of safe, shared care of patients. This might also prove useful in the event of complaints or for medico-legal reasons. For further details refer to the SDCEP Practice Support Manual.