Patient RecordsPatient RecordsVital SignsVital SignsChapters 26 and 27Chapters 26 and 27

Privacy PolicyPrivacy Policy

HIPAAHIPAA Requires that all dental practices have a written Requires that all dental practices have a written

privacy policyprivacy policy office will not use disclose or use PHI (Protected office will not use disclose or use PHI (Protected

Health Information) for any purpose other than Health Information) for any purpose other than treatment, diagnosis, and billing treatment, diagnosis, and billing

Patient Registration FormPatient Registration Form

Patient InfoPatient Info Name, DOB, address, email address, telephone Name, DOB, address, email address, telephone

numbers, employment info, spousal info and numbers, employment info, spousal info and emergency contact.emergency contact.

Insurance informationInsurance information Company name, employee, address and phone Company name, employee, address and phone

numbernumber

Patient forms cont.Patient forms cont.

Responsible PartyResponsible Party Person responsible for paymentPerson responsible for payment

Signature and dateSignature and date Patient verifies the accuracy of infoPatient verifies the accuracy of info

TemperatureTemperature

AverageAverage 98.698.6oo F F RangeRange 97.697.6oo F --- 99.6 F --- 99.6oo F (o) F (o)

RectalRectal +1 degree F -- Highest reading+1 degree F -- Highest reading

AxillaryAxillary -1 degree F-1 degree F

TERMSTERMS

PyrexiaPyrexia 100100oo F and above F and above

HyperthermiaHyperthermia 103103oo F and above F and above

HypothermiaHypothermia 9494oo F and below F and below

ElectronicElectronic fastest readingfastest reading

Oral glassOral glass 3 minutes3 minutes

RectalRectal most accuratemost accurate

Factors that affect TemperatureFactors that affect Temperature

Eating, drinking, smokingEating, drinking, smoking wait 15 min.wait 15 min. Time of day--Time of day-- lowest in AM, highest in PMlowest in AM, highest in PM EnvironmentalEnvironmental

Low in winter, high in summerLow in winter, high in summer Age of person– low in elderlyAge of person– low in elderly Physical activity—low at restPhysical activity—low at rest Emotional activity—high with anxietyEmotional activity—high with anxiety Disease condition—high with fever to fight Disease condition—high with fever to fight infectioninfection

PulsePulse

Average--Average-- 72 beats per minute72 beats per minute

Range--Range-- 60 – 90 beats per minute60 – 90 beats per minute

TermsTerms

Bradycardia--Bradycardia-- 60 and below60 and below

Tachycardia--Tachycardia-- 100 and above100 and above

CharacteristicsCharacteristics

Rate--Rate-- speed (normal, bradycardia, speed (normal, bradycardia, tachycardia)tachycardia)

Rhythm--Rhythm-- regularity (regular, irregular)regularity (regular, irregular)

Volume--Volume-- fullness (weak, bounding, fullness (weak, bounding, thready)thready)

Radial pulseRadial pulse

Most common pulse pointMost common pulse point

Factors that affect pulseFactors that affect pulse

ExerciseExercise StressStress Elevated temperatureElevated temperature DrugsDrugs IllnessIllness Sex (male or female)Sex (male or female)

ProcedureProcedure

Review the procedure on how to measure Review the procedure on how to measure pulsepulse

Count pulse full minute, hold pulseCount pulse full minute, hold pulse Count Respirations full minute and record Count Respirations full minute and record

RespirationsRespirations

Average--Average-- 18 breaths per minute18 breaths per minute

Range--Range-- 12 – 20 breaths per minute12 – 20 breaths per minute

TermsTerms

Accelerated--Accelerated-- 25 and above25 and above Tachypnea--Tachypnea-- rapid or shallow breathingrapid or shallow breathing Dyspnea--Dyspnea-- difficult or labored breathingdifficult or labored breathing Apnea--Apnea-- period of no respirationsperiod of no respirations Cheyne-Stokes--Cheyne-Stokes-- period of dyspnea followed by period of dyspnea followed by

apneaapnea Stertorous - snoring like respirationsStertorous - snoring like respirations Rales--Rales-- moist respirations “death rattle”moist respirations “death rattle” Review procedureReview procedure

Blood PressureBlood Pressure

Measures the force of the blood against the Measures the force of the blood against the walls of the arterieswalls of the arteries

Average--Average-- 120/80120/80

Range--Range-- 100/60 – 140/90100/60 – 140/90

TermsTerms

Hypertension--Hypertension-- 140/90 and above140/90 and above Hypotension--Hypotension-- 100/60 and below100/60 and below Systolic--Systolic-- first sound of blood pressure, first sound of blood pressure,

when heart contractswhen heart contracts Diastolic--Diastolic-- last sound, when heart last sound, when heart relaxesrelaxes Blood pressure is measured over the Blood pressure is measured over the

Brachial arteryBrachial artery

Factors that affect blood Factors that affect blood pressurepressure

Sex of patientSex of patient ExerciseExercise Stimulants (smoking due to nicotine)Stimulants (smoking due to nicotine) StressStress Hereditary factorsHereditary factors ObesityObesity

ProcedureProcedure

Review steps for taking blood pressureReview steps for taking blood pressure

ExamplesExamples

140/86 – 101.6140/86 – 101.6o o F – 90 – 20F – 90 – 20

pyrexiapyrexia 154/94 – 99.2154/94 – 99.2o o F - 88 – 16F - 88 – 16

hypertensionhypertension 80/40 – 98.2 F – 112 -2080/40 – 98.2 F – 112 -20

tachycardia, hypotension, shocktachycardia, hypotension, shock 132/78 – 98.6 F - 44 -14132/78 – 98.6 F - 44 -14

bradycardiabradycardia

TerminologyTerminology

PrefixPrefix High/fastHigh/fast

Hyper—Hyper— Tachy-Tachy-

Low/slowLow/slow Hypo-Hypo- Brady-Brady-

Dys- difficult/painful, ie dyspnesDys- difficult/painful, ie dyspnes A- without, ie apneaA- without, ie apnea

TerminologyTerminology

SuffixSuffix Thermia (temperature) ie, hyperthermiaThermia (temperature) ie, hyperthermia

Cardia (pulse, heart rate) ie tachycardia, Cardia (pulse, heart rate) ie tachycardia, bradycardiabradycardia

Pnea- (respirations, breathing) ie apneaPnea- (respirations, breathing) ie apnea

Tension (blood pressure) ie hypotensionTension (blood pressure) ie hypotension