The way a health history review is conducted directly impacts the amount of new and accurate information that is conveyed between patient and practitioner. While recommendations regarding the frequency of health history reviews are variable, an ethical cornerstone of our practice is conducting a thorough verbal and written review of the patient’s health at the opening of each appointment.
Hygienists often see patients at more frequent intervals than other health-care providers. Consequently, we have the opportunity to closely manage and support patients as they encounter and recover from various health conditions. Not only does this instill mutual trust, honesty, and concern for the patient as a total person, but it also provides us with a wealth of information regarding a patient’s total well-being, thereby enabling us to tailor our care. An effective health history review requires mutual effort but is often as simple as omitting non-effective phrasing and learning to communicate essential questions with compassion.
Compassionate listening versus automatic updating
In dental hygiene school, many of us are taught to focus on whether or not there are any changes to a person's health history, which prompts some clinicians to habitually ask yes or no questions that barely elicit new information. Many of us often scribble (or type) "no changes" in our patient's chart, make sure that no premedication is required, and then proceed with the rest of the appointment.
While this is an easy habit to cultivate, spending an extra minute to research the patient’s medications on a health history form is critical to uncovering details. Reviewing the health history in a more thorough manner is a necessary step where we must make an effort to learn about each person in totality.
Bickley defines the health history as "a current collection of organized information unique to an individual. relevant aspects of the history include biographical, demographic, physical, mental, emotional, sociocultural, sexual, and spiritual data.”(1) That said, we could consider any detail that pertains to a patient’s physical (medications, allergies, surgeries), emotional (interpersonal relationships, mental health, life changes), or social state (gender identity, family life, spiritual practice) as relevant to review and record under the medical history update.
The health history review as an opportunity, not an obligation
The term "ethical responsibility" applies to much of what we do in dental hygiene practice. However, components of an appointment that are our ethical responsibility often begin to feel obligatory and automatic unless they are viewed as meaningful. This negative connotation to some of our job duties often carries into our interactions and may translate to patients as a lack of concern or a lack of significance.
Dr. Esther Wilkins identified responsibility as integral to our practice and states that to "provide oral health care utilizing high levels of professional knowledge, judgment, and skill" is central to our responsibilities when dealing with patients.(2). This includes applying knowledge about specific systemic issues and offering guidance on how to manage disease in the oral cavity as well as the rest of the body.
Consequently, I think it would benefit us as providers to view the medical history review as a positive opportunity to learn as much as we can about our patients and to connect with them on a deeper level. Learning more about what our patients are experiencing systemically enables us to tailor our treatment and provide helpful recommendations based on their current condition. (We've long known that one-size-fits-all recommendations do a disservice to our patients and downplay the amount of education that we have as providers.) Keeping an accurate and up-to-date record of verbal exchanges between patient and provider can make reviewing a health history an enjoyable and compassionate undertaking if communication is executed the right way.
Social graces as an essential component
While often overlooked as essential to a hygiene visit, social graces act as an invitation for disclosure of pertinent information and make encounters with any health care provider more personal, effective, and meaningful. Spending several minutes to inquire about a patient’s life while making small talk can often make transitioning into technical questions about health status more natural.
It is important to open each hygiene appointment with a brief dialogue about recent happenings in a client’s life. From there, a conversation can ensue regarding a patient’s health status at their last appointment. Any changes that have transpired can be noted specifically wherever updates are recorded. An initial communication about the patient as a total person signifies that there is regard for them in a context larger than that of clinical dental hygiene. This ultimately puts patients at ease and makes them much more comfortable when asked to disclose personal health details.
It’s not what you ask; it's how you ask it
Patience is a cornerstone of a thorough and effective health history review, because a history is dynamic and exists on a continuum. Similarly, a new patient’s level of comfort when disclosing personal information is variable and differs between each interaction. Rather than remain satisfied with a "yes" or "no" response, it's important to review and verbally list all previously collected information regarding a patient's health, especially when encountering a new individual for the first time.
Often, medications change in dosage or specific brand between appointments, and these details are worth noting. Expressing an interest in a patient’s health and demonstrating that you’ve done your research is usually enough of an incentive for patients to share their story and to disclose new information regarding their health status.
Typically, I will segue into several simple questions after a patient is seated and social graces have been conducted. An open-ended question such as, “How is your health?” resonates strongly and usually prompts a response beyond the general “yes/no” that we’ve come to accept as standard. Specific questions regarding the brands, dosages, and frequencies that medications are used can be offered by listing what is already written, and corrections can be made accordingly.
The challenge lies in the details: Some practical examples
While some patients will provide candid and thorough responses to a health history update, many present with speech and body language that demonstrates impatience or a lack of perceived importance. Often, hygienists have to “play detective” and meet responses with follow-up questions that clarify what a patient truly means.
This has much to do with differences in health literacy between patients and their providers. For example, a patient could respond with confidence that they do not have a specific condition or take any medications. Patients may assume that a disclosure about chronic conditions such heart disease or diabetes is unimportant or unrelated to dental treatment. Since alternative medicine and naturopathy is still in vogue, patients may also omit to mention herbal supplements and vitamins that they assume are not true medications. A review of the specific medications listed can clarify what conditions a patient neglected to check on an initial health history.
Likewise, patients may assume that allergies are unimportant because they do not pertain to direct dental treatment. While latex, codeine, and sulfa drugs are some of the most commonly noted allergies, patients may omit allergies to dye, flavors, foods, shellfish, and iodine due to a perceived lack of importance. However, each of these substances could potentially affect dental treatment, inevitably influencing our choices of local anesthetics, prophy pastes, and irrigation solutions during periodontal therapy. For these reasons, it’s perfectly acceptable (and even advisable) to delve deeper and clarify, piecing together information to form an accurate picture of a person’s health status.
The heart in our art
In conclusion, relating with patients is of paramount importance and often dictates whether or not they feel comfortable, respected, and cared for in a clinical setting. One major opportunity to connect and elicit important information is during the health history update.
By taking the time to listen, document, and manage vital information about those we treat, we are utilizing our very important skill set and solidifying our value as health care professionals.
As Bickley stated, “The health history interview is a conversation with a purpose. A well-executed review can promote a feeling of connectedness, of being deeply heard and understood, and reduces this feeling of isolation and despair. This feeling is the very heart of healing.”(1)
Lauren Hapeman, RDH, BSDH is a clinical dental hygienist in Philadelphia, PA. She currently works in private practice four days per week and utilizes a public health dental hygiene practitioner license to work in non-traditional settings. Her professional interests include increasing access to care in urban communities, culturally competent communication, periodontal therapy, and establishing standards for ethical dental hygiene practice. She can be reached via e-mail at: Lauren.firstname.lastname@example.org