Patient Records Vital Signs Chapters 26 and 27

Privacy Policy HIPAA HIPAA Requires that all dental practices have a written privacy policy Requires that all dental practices have a written privacy policy office will not use disclose or use PHI (Protected Health Information) for any purpose other than treatment, diagnosis, and billing office will not use disclose or use PHI (Protected Health Information) for any purpose other than treatment, diagnosis, and billing

Patient Registration Form Patient Info Patient Info Name, DOB, address, address, telephone numbers, employment info, spousal info and emergency contact. Name, DOB, address, address, telephone numbers, employment info, spousal info and emergency contact. Insurance information Insurance information Company name, employee, address and phone number Company name, employee, address and phone number

Patient forms cont. Responsible Party Responsible Party Person responsible for payment Person responsible for payment Signature and date Signature and date Patient verifies the accuracy of info Patient verifies the accuracy of info

Temperature Average98.6 o F Average98.6 o F Range97.6 o F o F (o) Range97.6 o F o F (o) Rectal+1 degree F -- Highest reading Axillary-1 degree F

TERMS Pyrexia100 o F and above Pyrexia100 o F and above Hyperthermia103 o F and above Hyperthermia103 o F and above Hypothermia94 o F and below Hypothermia94 o F and below

Electronicfastest reading Electronicfastest reading Oral glass3 minutes Oral glass3 minutes Rectalmost accurate Rectalmost accurate

Factors that affect Temperature Eating, drinking, smokingwait 15 min. Eating, drinking, smokingwait 15 min. Time of day--lowest in AM, highest in PM Time of day--lowest in AM, highest in PM Environmental Environmental Low in winter, high in summer Low in winter, high in summer Age of person– low in elderly Age of person– low in elderly Physical activity—low at rest Physical activity—low at rest Emotional activity—high with anxiety Emotional activity—high with anxiety Disease condition—high with fever to fight infection Disease condition—high with fever to fight infection

Pulse Average--72 beats per minute Average--72 beats per minute Range--60 – 90 beats per minute Range--60 – 90 beats per minute

Terms Bradycardia--60 and below Bradycardia--60 and below Tachycardia--100 and above Tachycardia--100 and above

Characteristics Rate--speed (normal, bradycardia, tachycardia) Rate--speed (normal, bradycardia, tachycardia) Rhythm--regularity (regular, irregular) Rhythm--regularity (regular, irregular) Volume--fullness (weak, bounding, thready) Volume--fullness (weak, bounding, thready)

Radial pulse Radial pulse Most common pulse point Most common pulse point

Factors that affect pulse Exercise Exercise Stress Stress Elevated temperature Elevated temperature Drugs Drugs Illness Illness Sex (male or female) Sex (male or female)

Procedure Review the procedure on how to measure pulse Review the procedure on how to measure pulse Count pulse full minute, hold pulse Count pulse full minute, hold pulse Count Respirations full minute and record Count Respirations full minute and record

Respirations Average--18 breaths per minute Average--18 breaths per minute Range--12 – 20 breaths per minute Range--12 – 20 breaths per minute

Terms Accelerated--25 and above Accelerated--25 and above Tachypnea--rapid or shallow breathing Tachypnea--rapid or shallow breathing Dyspnea--difficult or labored breathing Dyspnea--difficult or labored breathing Apnea--period of no respirations Apnea--period of no respirations Cheyne-Stokes--period of dyspnea followed by apnea Cheyne-Stokes--period of dyspnea followed by apnea Stertorous - snoring like respirations Stertorous - snoring like respirations Rales--moist respirations “death rattle” Rales--moist respirations “death rattle” Review procedure Review procedure

Blood Pressure Measures the force of the blood against the walls of the arteries Measures the force of the blood against the walls of the arteries Average--120/80 Average--120/80 Range--100/60 – 140/90 Range--100/60 – 140/90

Terms Hypertension--140/90 and above Hypertension--140/90 and above Hypotension--100/60 and below Hypotension--100/60 and below Systolic--first sound of blood pressure, when heart contracts Systolic--first sound of blood pressure, when heart contracts Diastolic--last sound, when heart relaxes Diastolic--last sound, when heart relaxes Blood pressure is measured over the Brachial artery Blood pressure is measured over the Brachial artery

Factors that affect blood pressure Sex of patient Sex of patient Exercise Exercise Stimulants (smoking due to nicotine) Stimulants (smoking due to nicotine) Stress Stress Hereditary factors Hereditary factors Obesity Obesity

Procedure Review steps for taking blood pressure Review steps for taking blood pressure

Examples 140/86 – 101.6o F – 90 – 20 pyrexia 154/94 – 99.2o F - 88 – 16 hypertension 80/40 – 98.2 F – tachycardia, hypotension, shock 132/78 – 98.6 F bradycardia

Terminology Prefix Prefix High/fast High/fast Hyper— Hyper— Tachy- Tachy- Low/slow Low/slow Hypo- Hypo- Brady- Brady- Dys- difficult/painful, ie dyspnes Dys- difficult/painful, ie dyspnes A- without, ie apnea A- without, ie apnea

Terminology Suffix Suffix Thermia (temperature) ie, hyperthermia Thermia (temperature) ie, hyperthermia Cardia (pulse, heart rate) ie tachycardia, bradycardia Cardia (pulse, heart rate) ie tachycardia, bradycardia Pnea- (respirations, breathing) ie apnea Pnea- (respirations, breathing) ie apnea Tension (blood pressure) ie hypotension Tension (blood pressure) ie hypotension