Chapter 15: Analysis of Information with Clinical Applications

1. Chapter 15: Analysis of Information with Clinical Applications

2. Final Questions • “Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?” • “Name of physician or dentist making the recommendation and phone number.” • Intention • Resolve practitioner recommendations • Assist client in understanding recommendations • May result in previous recommendation being rescinded, based on current guidelines

3. Final Questions (cont’d) • “Do you have any disease, condition, or problem not listed above that you think I should know about?” • “Please explain.” • Client’s response would require: • Analysis of impact on planned procedures • Effects of medications associated with newly reported condition

4. Client/Legal Guardian Signature and Date • Reminder of importance of disclosing all health issues prior to treatment • Acknowledgement of accuracy and truthfulness • Disclaimer of dentist’s responsibility for errors due to omission of information in health history • Signature • Client’s if client is 18 or older • Legal guardian’s if client is under 18 • Date

5. “For Completion by Dentist” Section • Purpose • Analysis of health history information • Clinical & management decisions based on health history • Protection against lawsuits • Types of information included • Verification of information reported by client • Medical consultations completed • Consideration of pertinent laboratory data • Relationship of information to planned oral procedures

6. Privacy of Health Information and HIPAA Regulations • Health Insurance Portability & Accountability Act (HIPAA) • Established in 1996 • Increased accessibility & affordability of health insurance • Ability to keep insurance after job loss • Privacy of electronically transmitted health information • Protection of personal health information • Availability of written policies to clients • Administrative, physical, & technical safeguards

7. Privacy Behaviors Allowed and Required by HIPAA • Allowed • Call out client name to be seated for treatment • Have clients sign in • Place chart markers related to safety alerts (e.g., allergies) • Required • Ensure privacy when discussing client treatment in office • Store client dental charts away from public view

8. Requirements of Dental Office in HIPAA • Learn HIPAA requirements • Appoint a compliance officer • Receive complaints • Develop office policies on security & privacy protocols • Provide written policies to clients • Secure client signature to verify receipt of policies • Develop employee training sessions • Establish discipline protocol for violations

9. Requirements of Dental Office in HIPAA (cont’d) • Prepare privacy agreements with business partners • Post written notice of privacy assurance in public areas • Provide clients the right to: • Access personal health information • Identify errors • Request changes • Develop self-audit procedure to monitor compliance • Document training sessions & personnel trained

10. Office Preparation for Emergency Management: Suggested Protocol • Written emergency plan • Basic life support (BLS) certification for all staff • Regular cardiopulmonary resuscitation (CPR) training • Periodic office emergency drills • Protocols for unconsciousness, cardiac arrest • Emergency kit & knowledge of how to use it • Administration of oxygen • Documentation of emergency events in client records