The Art of History Taking
By Rose Nierman, RDH
President, Nierman Practice Management
1-800-879-6468
http://www.dentalwriter.com/
There is no argument that personal one on one history taking
for orofacial pain is a skill and an art form.
At times the patient might
assume that you already know why he is there and volunteer little.
Others
may offer an abbreviated history or feel reluctant to talk about their problem.
Take the example of a 49 year old male executive who presents with jaw locking.
He states that he has no headaches, however his medications show a history of daily
Fiorinal and Skeletal which “handles any neck pain discomfort and facial muscle
discomfort”.
We’ve encountered the patient who denies high blood pressure
on the medical history but is taking blood pressure medication. It is up to the
history taker to ask leading questions which draw out information for care and documentation.
Questions designed to elicit responses showing location, onset, duration, character
and severity of pain assist in treatment and become part of your report writing
and documentation. Other questions relating to previous diagnosis, prior treatments,
additional health problems family or social history will strengthen documentation
and treatment.
Most orofacial pain practices are familiar with the concept
of SOAP notes. History taking is the
S or subjective portion of the SOAP
notes and includes the patient's personal data, medical history, family history,
social history and complaint.
How to Write SOAP Notes
SOAP stands for SUBJECTIVE, OBJECTIVE, ASSESSMENT and PLAN.
SOAP notes and reports improve insurance reimbursement by demonstrating medical
necessity for orofacial pain conditions.
It’s known that there is a direct
correlation between the level of history taking and the amount of reimbursement
from insurers and these levels need to be documented and match up to the level of
CPT coding submitted.
The primary focus of this article is the subjective
portion of the SOAP notes, however, complete SOAP notes for standard reporting should
include:
S: Subjective Data: Symptoms which represent
the patient’s story are checked on a patient questionnaire or verbally given by
the patient or significant other (family or friend).
These subjective notes
include the patient's descriptions of pain or discomfort, the presence of fatigue
or dizziness and a multitude of other descriptions of dysfunction, discomfort, or
complaints.
O: Objective: Objective outlines observations
that the dentist and assistant can actually see, hear, touch or feel. Included in
objective observations are measurements revealed during clinical examination and
from diagnostic tests such as x-rays, laboratory tests and physical findings.
A: Assessment: Assessment follows
the objective observations and consists of the diagnosis, prognosis, restrictions,
causation and other factors influencing the status of the patient. In some cases
the diagnosis may not be clear and could include several diagnosis possibilities
as a working diagnosis or initial clinical impression.
P: Plan: The plan may include laboratory
and/or radiological tests ordered for the patient, medications ordered, treatments
performed (e.g., orthotic, injections), patient referrals (i.e. to a specialist
or to the primary care physician) and patient follow up directions. Procedures for
treatment should be thoroughly defined including any plans for collecting information
for further diagnosis.
According to the American Medical Association and Health
Care Financing Administration the history taking component of the examination should
include some or all of the following elements:
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Review of Systems (ROS)
- Past Personal, Family, and/or Social history (PFSH)
Figure 1 shows HPI and some common examples of elements
of HPI
Figure
1 Sample HPI Chart for Orofacial Pain
Location
|
|
Character
|
Severity
|
Head
|
Rarely
|
Dull
|
No Pain
|
Neck
|
Hours
|
Sharp
|
Mild
|
Face
|
Days
|
Burning
|
Moderate
|
Ear
|
Always
|
Pressure
|
Severe
|
After introducing oneself, the history taker engages the
patient in conversation to elicit responses that will result in a complete HPI report.
Questions such as, "Why are you here today? "What can I help you with today? or
"What seems to be your primary problem?" will generally direct the patient to state
the main complaint.
According to Dr. Robert Morrish of Danville, Ca 1,
history taking for Orofacial Pain could also include the following basic questions:
Onset:
Refers to when the problem first became apparent to the
patient.
Was there anything associated with the onset?
Constant vs. Intermittent:
Refers to whether the problem is cyclic, whether the pain
comes and goes.
Note: If the problem is pain, the constant vs. intermittent
would be determined by a question like "Are you ever free of pain?"
Course:
Is the problem getting better or worse?
Severity: Is the problem a major or minor concern
to the
patient? Does it keep the patient awake at night? Does
it interfere with his job or other activities?
Previous Diagnosis:
Have the patient seen any other professional person regarding
this problem?
Has anyone told the patient what the problem is called?
Treatment and Results to Date:
Has another dentist, physician or the patient himself ever treated
this problem before?
What were the results?
Review of Systems (ROS)
An ROS is a listing of any signs or symptoms the patient
may be experiencing or has experienced organized by body system. It is a review
of systems directly related to the pain problem(s) identified in the HPI as well
as any pertinent current medical problem(s). There are 14 possible systems: constitution
(general health, fever, weight loss), integumentary, musculoskeletal, eyes, ears/nose/mouth/throat,
neurological, cardiovascular, hematologic, lymphatic, respiratory, allergic/immunologic,
gastrointestinal, psychiatric, genitourinary, and endocrine.
A more involved review of systems might be required for
a patient with diabetes or heart problems in contrast to a more healthy patient.
The level of reimbursement will be higher for the more comprehensive review of systems,
although medical necessity must be established to justify the higher level.
Past Personal, Family, and/or Social History (PFSH)
There are three parts to the PFSH:
- past personal (current medications, allergies, prior
illnesses, injuries, operations and
admissions)
- family (members living, health status, hereditary conditions
related to the present complaint or illness)
- social (marital status, employment, tobacco, alcohol,
drug use).
To facilitate the HPI and PFSH, mailing a history questionnaire
to patients before their appointment will save time. Staff meetings are a good time
to discuss the elements of history taking and incorporate history taking skills
and role playing.
Rose Nierman is founder and president of Nierman Practice
Management, the home of DentalWriter™ SOAP report Software, CrossCode™ Manual and
Software and The Complete TMJ Manager Manual.
She can be reached at 1-800-879-6468
or at
RNierman@aol.com. Visit her website at DentalWriter.com.
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