The Dental Patient
Health Insurance Portability and Accountability Act (HIPAA)
Patients are the only reason a dental practice exists. And your primary responsibility to these patients is to be a component of the dental team that provides quality patient care. This includes making patients feel welcome and comfortable in the practice. It also includes maintaining the patient’s safety and well-being during treatment. See Box 11-1: The Assistant’s Responsibilities to the Patient.
The Patient Record
Before any treatment can begin, the dentist will request personal and clinical information from the patient. The patient record is an important legal document that maintains this information about a patient. Each patient has a separate record. This information is obtained by asking the new patient to complete the printed forms at the first visit.
There are circumstances when a patient may be unable to complete the forms, such as a language barrier, not being able to read, or being visually impaired. When this is apparent, assist the patient by helping him or her to complete the form’s and by answering any questions necessary to help the patient provide the required data.
The patient registration form is completed and used primarily for the business office in management of the account. Information gathered here must be complete and accurate (Figure 11-1) and includes the following:
• Responsible party: Patients are not always responsible for payment of their own dental expenses. This section gathers information concerning the individual who accepts this responsibility. Information required here includes the responsible party’s full name, address, home and work telephone numbers, and employment information. Be sure the responsible party signs the release of information and assignment of benefits.
• Insurance information: This section gathers data required in completing dental insurance claims for the patient. The subscriber should provide specific insurance information, such as the group or policy number. Usually the responsible party is also the insurance plan subscriber. It is customary to make a photocopy of the patient’s insurance card.
The patient record also consists of a medical and dental history completed by the patient and a record of all examination findings and treatment descriptions as dictated by the dentist. The patient’s radiographs, laboratory prescriptions, and any correspondence will also be stored within the patient record. The patient must give consent by signing a release of information form before a consultation between the dentist and the physician can take place.
The medical history asks questions regarding the patient’s past medical history, present physical condition, chronic conditions, allergies, and medications. Each new patient must complete a medical history form before treatment can begin (Figure 11-2).
The patient’s signature on the form indicates that he or she has provided the information and takes responsibility for its accuracy.
Returning patients are asked to update their medical history at each visit. The patient should sign the form to indicate that the information is accurate and up-to-date (Figure 11-3).
The dentist may also wish to consult the patient’s physician regarding health problems, particularly if the patient is medically compromised. (Medically compromised is defined as a patient with an illness or physical condition that may influence the way dental treatment is provided.)
A medication history, which is an essential part of the medical history, is a record of all the medications a patient is currently taking. These include prescription drugs, over-the-counter drugs, vitamins, and any other drugs. This history is particularly important in older patients, many of whom have chronic conditions and are taking several prescribed and over-the-counter medications.
The dentist needs to be aware of these medications because either the medicine or the condition for which it was prescribed may modify the selection of anesthetic, premedication, and procedures when providing dental treatment.
If the patient has any known allergies, it is extremely important that the dental team be aware of these. A reaction could increase with severity each time the individual comes into contact with the substance. For this reason, it is important to ask about both known and suspected allergies.
Of particular concern in the dental setting are allergies to latex, antibiotics, pain medication, and local anesthetic solutions (Box 11-2).
If the patient has a predisposing medical condition that could impact decisions regarding dental treatment, this information must be indicated on the inside cover of the patient record. A brightly colored “ALERT” sticker is placed for the attention of the dental team. The alert sticker should never be placed on the outside of a patient record because this would violate dentist-patient confidentiality and the privacy of the patient.
The patient’s dental history offers important clues in reference to previous dental care. Questions can include how recently the patient received dental treatment, the frequency of dental visits, and the patient’s attitude concerning the importance of the appearance of his or her own teeth and dental care.
HIPAA states that additional authorization and consent from the patient would be required if the disclosure of documents were to be used for healthcare operations, research, or public need.
It is necessary to be in a private or semiprivate area when reviewing a health history or any specific content of a patient record.
Additional information about HIPAA can be found at: www.ada.org/prof/resources/topics/hipaa/index.asp.
The clinical examination form is the most detailed document in the patient record. This form provides the dental team all examination data from the past, present, and future. Each time a patient comes in for an appointment, this form will be updated (Figure 11-5).