History Taking & Clinical Examination in Dentistry Charu M Marya
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IntroductionCHAPTER 1

“Accurate diagnosis of a disease depends on the art of taking case history.”
Diagnosis is the art and science of recognizing the presence and nature of disease by an evaluation of its various distinctive signs, symptoms and characteristics. As modern rational therapy is based upon the scientific interpretation of the changes in structure and function of the body tissues, the importance of an accurate diagnosis is at once evident. There can be only one true diagnosis and the success of treatment is dependent upon its establishment.
Professional, ethical and legal responsibilities dictate that a complete chart and record documenting all the aspects of each patient's dental treatment must be maintained. Good records facilitate the provision of effective dental care and ensure the continuity and comprehensiveness of oral/dental health services.
Case history is an important and integral part of treatment.
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Case history is defined as planned professional conversation that enables a patient to communicate his/her feelings, fear and sequence of events leading to the problem for which the patient seeks professional assistance, to the clinician so that patient's real or suspected illness and mental attitude can be determined. Ideally case history is taken in a consultation room or a private office in which the surroundings and the conditions are entirely friendly and not like the dental operating room. In many occasions, a properly prepared case history alone is sufficient to diagnose the disease without examining the patient.
Of all the important diagnostic tools, the art of listening is the most underrated. Yet careful and attentive listening establishes patient-dentist rapport, understanding and trust. Eliciting accurate, detailed and unbiased information from a patient is a skilled task and not simply a matter of recording the patient's responses to a checklist of questions. Avoid interrupting patients, particularly as they begin to tell you the story of the presenting features of the illness. Recognizing the patient's need to talk without interruption and being a good listener will greatly help you establish a good relationship quickly (Fig. 1.1).
A case history is of immense value in the following ways:
  • To provide information regarding etiology and establish diagnosis of oral conditions.
  • To reveal any medical problem necessitating precautions, modifications during appointments so as to ensure that dental procedures do not harm the patient and also to prevent emergency situations.
  • Evaluation of other possible undiagnosed problems.
  • Discovery of communicable diseases.
  • Gives an insight into emotional and psychological factors.
  • For effective treatment planning. It enables dentists to obtain information necessary to provide appropriate and individualized care.3
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    Fig. 1.1: Listen to the patient
  • Record maintenance for future reference and periodic follow-up.
  • To prevent medical complications and thus minimize detrimental effects to the patient and the possibility of medico-legal complications for the dentist.
 
RISK MANAGEMENT
In recent years, the requirements for dental records management have been redefined, especially as they relate to documentation, release of information and storage. Dentists are expected to be familiar with current expectations and to ensure that their staff members understand and adhere to the updated protocols.4
Patient records must be accurate, well-organized, legible, readily accessible and understandable. If the dentist who has taken the history and noted the record is not available to treat the patient for any reason, another dentist should be able to easily review the chart and carry on with the care of the patient.
 
CONFIDENTIALITY
Patients have a right to expect that their dental health information will be kept confidential.
  • Patients have a right (with a few exceptions) to review and obtain a copy of their dental records including consultation reports of other practitioners.
    It is appropriate, where patient consent has been obtained, to share dental and medical records with other health professionals as necessary to ensure continuity and quality of care.
  • Every dental team member involved in a patient's care should maintain the confidentiality and security of a patient's dental records, only sharing them with other healthcare professionals for the purpose of assisting in providing optimal care.
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  • Dental records should only be disposed of in a manner that ensures the confidentiality of the information is maintained.
According to Dental Recordkeeping Guidelines (2010) by College of Dental Surgeons of British Columbia (CDSBC):
 
 
Essentials of Recordkeeping
The extent of detail required for each record will vary; however, certain baseline data should be common to all the dental patients.
This information includes:
  • Accurate general patient information
  • A medical history that is periodically updated
  • A dental history
  • An accurate description of the conditions that are present on initial examination, including an entry such as “within normal limits” where appropriate
  • An accurate description of ongoing dental status at subsequent appointments
  • A record of the significant findings of all the supporting diagnostic aids, tests or referrals such as radiographs, study models, reports from specialists
  • All clinical diagnoses and treatment options
  • A record that all reasonable treatment planning options were discussed with the patient
  • The proposed and accepted treatment plan
  • A notation that informed consent was obtained
  • Assurance that patient consent was obtained for the release of any and all patient information to a third party
  • A description of all treatment that was performed, materials and drugs used and, where appropriate, the prognosis and outcome of the treatment
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  • Details about referrals
  • An accurate financial record.
The barriers to obtain a complete medical history by preprinted forms followed by appropriate in-depth questions or by direct query of patients include (but are not limited to) time constraints imposed by busy practices, the unwillingness of patients to reveal aspects of their medical status, and the impatience of the dentist while listening to the patients, as well as a variety of religious and moral issues that may arise.