Patient Assessment Considerations

Understanding a patient’s medical history is a critical element of the patient assessment when providing dental care to any patient, but, is especially important when a patient has been diagnosed with a chronic disease. The medical history should include vital signs and detailed discussions about the patient’s medications, medical condition, disease prognosis, comorbidities, patient’s perception of their oral status, physical limitations, and cognitive status (level of cooperation and mental state).10,11 Tools are available to help dental providers understand a patient’s physical limitations and cognitive status so that appropriate appointment modifications and accommodations can be made. Branson developed a patient assessment form, specific for dental providers, to aid in gathering this information (Figure 1).12 This guide provides a structured way to examine mobility, positioning, approachability, verbal and visual interactions, ability to open mouth and turn head, and supportive equipment that is needed.12

Dental providers should collaborate with the patient’s health care team (family, caregivers, physician, nurses, occupational therapists, psychiatrists, and other health professionals) to gain a better understanding and confirm medical history findings. Communication with these individuals should be ongoing and documented throughout each phase of dental treatment.10 An interdisciplinary approach is critical for success. The following sections in this course provides specific information about Alzheimer’s disease, arthritis, COPD, depression, diabetes, heart disease, high blood pressure, multiple sclerosis, Parkinson’s disease, and stroke.

Figure 1. Branson Patient Assessment Form.
Chart showing a patient assessment form developed specifically for dental providers.
Adapted with permission from Branson, 2013.
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