Chapter 15 Analysis of Information with Clinical Applications

Chapter 15: Analysis of Information with Clinical Applications Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

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recommendations – Assist client in understanding recommendations • May result in previous recommendation being rescinded, based on current guidelines Copyright © 2015 Wolters Kluwer • All Rights Reserved

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 Copyright © 2015 Wolters Kluwer • All Rights Reserved

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 Copyright © 2015 Wolters Kluwer • All Rights Reserved

“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 Copyright © 2015 Wolters Kluwer • All Rights Reserved

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 Copyright © 2015 Wolters Kluwer • All Rights Reserved

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 Copyright © 2015 Wolters Kluwer • All Rights Reserved

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 Copyright © 2015 Wolters Kluwer • All Rights Reserved

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 Copyright © 2015 Wolters Kluwer • All Rights Reserved

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 Copyright © 2015 Wolters Kluwer • All Rights Reserved