The Art of History Taking  

By Rose Nierman, RDH

President, Nierman Practice Management

1-800-879-6468

http://www.dentalwriter.com/ 

There is no argument that personal one on one history taking for orofacial pain is a skill and an art form.   At times the patient might assume that you already know why he is there and volunteer little.   Others may offer an abbreviated history or feel reluctant to talk about their problem. Take the example of a 49 year old male executive who presents with jaw locking.   He states that he has no headaches, however his medications show a history of daily Fiorinal and Skeletal which “handles any neck pain discomfort and facial muscle discomfort”.   We’ve encountered the patient who denies high blood pressure on the medical history but is taking blood pressure medication. It is up to the history taker to ask leading questions which draw out information for care and documentation.   Questions designed to elicit responses showing location, onset, duration, character and severity of pain assist in treatment and become part of your report writing and documentation. Other questions relating to previous diagnosis, prior treatments, additional health problems family or social history will strengthen documentation and treatment.  

Most orofacial pain practices are familiar with the concept of SOAP notes. History taking is the S or subjective portion of the SOAP notes and includes the patient's personal data, medical history, family history, social history and complaint.    

How to Write SOAP Notes 

SOAP stands for SUBJECTIVE, OBJECTIVE, ASSESSMENT and PLAN.  SOAP notes and reports improve insurance reimbursement by demonstrating medical necessity for orofacial pain conditions.   It’s known that there is a direct correlation between the level of history taking and the amount of reimbursement from insurers and these levels need to be documented and match up to the level of CPT coding submitted.   The primary focus of this article is the subjective portion of the SOAP notes, however, complete SOAP notes for standard reporting should include:  

S: Subjective Data: Symptoms which represent the patient’s story are checked on a patient questionnaire or verbally given by the patient or significant other (family or friend).   These subjective notes include the patient's descriptions of pain or discomfort, the presence of fatigue or dizziness and a multitude of other descriptions of dysfunction, discomfort, or complaints.  

O: Objective: Objective outlines observations that the dentist and assistant can actually see, hear, touch or feel. Included in objective observations are measurements revealed during clinical examination and from diagnostic tests such as x-rays, laboratory tests and physical findings.    

A: Assessment:  Assessment follows the objective observations and consists of the diagnosis, prognosis, restrictions, causation and other factors influencing the status of the patient. In some cases the diagnosis may not be clear and could include several diagnosis possibilities as a working diagnosis or initial clinical impression.  

P: Plan: The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., orthotic, injections), patient referrals (i.e. to a specialist or to the primary care physician) and patient follow up directions. Procedures for treatment should be thoroughly defined including any plans for collecting information for further diagnosis.  

According to the American Medical Association and Health Care Financing Administration the history taking component of the examination should include some or all of the following elements:

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Review of Systems (ROS)
• Past Personal, Family, and/or Social history (PFSH)

Figure 1 shows HPI and some common examples of elements of HPI  

     Figure 1 Sample HPI Chart for Orofacial Pain          

After introducing oneself, the history taker engages the patient in conversation to elicit responses that will result in a complete HPI report.   Questions such as, "Why are you here today? "What can I help you with today? or "What seems to be your primary problem?" will generally direct the patient to state the main complaint.  

According to Dr. Robert Morrish of Danville, Ca ¹, history taking for Orofacial Pain could also include the following basic questions:  

Onset:

Refers to when the problem first became apparent to the patient.   Was there anything associated with the onset? 

Constant vs. Intermittent:

Refers to whether the problem is cyclic, whether the pain comes and goes.   Note:  If the problem is pain, the constant vs. intermittent  would be determined by a question like "Are you ever free of pain?" 

Course:

Is the problem getting better or worse? 

Severity: Is the problem a major or minor concern to the  patient?  Does it keep the patient awake at night?  Does it interfere with his job or other activities?  

Previous Diagnosis:

Have the patient seen any other professional person regarding this problem?

Has anyone told the patient what the problem is called?     

Treatment and Results to Date:

Has another dentist, physician or the patient himself ever treated this problem before?   What were the results?

Review of Systems (ROS)

An ROS is a listing of any signs or symptoms the patient may be experiencing or has experienced organized by body system. It is a review of systems directly related to the pain problem(s) identified in the HPI as well as any pertinent current medical problem(s). There are 14 possible systems: constitution (general health, fever, weight loss), integumentary, musculoskeletal, eyes, ears/nose/mouth/throat, neurological, cardiovascular, hematologic, lymphatic, respiratory, allergic/immunologic, gastrointestinal, psychiatric, genitourinary, and endocrine.

A more involved review of systems might be required for a patient with diabetes or heart problems in contrast to a more healthy patient.   The level of reimbursement will be higher for the more comprehensive review of systems, although medical necessity must be established to justify the higher level.

Past Personal, Family, and/or Social History (PFSH)

There are three parts to the PFSH:

• past personal (current medications, allergies, prior illnesses, injuries, operations and   admissions)
• family (members living, health status, hereditary conditions related to the present complaint or illness)
• social (marital status, employment, tobacco, alcohol, drug use).

To facilitate the HPI and PFSH, mailing a history questionnaire to patients before their appointment will save time. Staff meetings are a good time to discuss the elements of history taking and incorporate history taking skills and role playing.

Rose Nierman is founder and president of Nierman Practice Management, the home of DentalWriter™ SOAP report Software, CrossCode™ Manual and Software and The Complete TMJ Manager Manual.   She can be reached at 1-800-879-6468 or at RNierman@aol.com.  Visit her website at DentalWriter.com. 

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