Patient history Objectives:

patient’s medical

Social

Family

Dental experiences

Methods:

Interview

Health questionnaire

Combined method

Components:

Biographic data

Chief complaint and its history

Social history

Emotional and behavioral history

Family history

Medical history and systems review:

past illnesses

present illnesses

Dental history

Systems review

Level 1: A patient with no systemic disease

Level 2: A patient with mild systemic disease

Level 3: A patient with severe systemic disease

Level 4: A patient with life-threatening systemic

disease

Systems review

Cardiovascular system

Respiratory system

Central nervous system

Gastrointestinal system

Genitourinary system

Musculoskeletal system

Endocrine system

Integument (skin, hair and nails)

Ears and Eyes

Vital signs:

Blood pressure

Pulse

Respiratory rate

Temperature

Weight and height

Consultation and referral Indications:

Diagnosis

Patient’s status

Specialized treatment

Second opinion

Lack of response

Rules for the referring clinician:

1. The appointment with the consultant should be made through the office of the referring clinician while the patient is still there.

2. A consultation sheet should be sent with the patient. This sheet should identify the patient, give the date of the referral, and state the exact reason for the referral.

3. The consultant must be given all pertinent information: history, present medications, radiographs, laboratory findings, diagnostic casts, and chronology of previous treatments.

4. The referring clinician should fully explain dental

procedures and their impact on the on medical conditions.

5. The referring clinician should have his or her name,

address, and phone number.

6. Say “thank you” on the consultation.

7. The referring clinician should always check to be sure

that the patient actually went to the consultant.

Rules for the consultant:

1. The consultation is a request for a professional opinion.

2. The professional opinion should be expressed in

complete written form on the consultation sheet and

returned to the referring clinician.

3. The opinion should include a differential diagnosis and

specific recommendations for case management.

4. The consultant is free to take any additional radiographs or perform any needed tests to establish an opinion.

5. The findings of the consultation may or may not be revealed to the patient.

6. The referring clinician should be immediately contacted by telephone if any emergencies result from the consultation process.

7. The primary referring clinician remains the dentist of record.

A referral in not a consultation. A referral is actually a request for the services of a professional colleague in the management of a patient.

All findings from the consultations and all treatment provided during referrals must be accurately recorded in the patient’s dental record.