Patient Assessment, Diagnosis, and Treatment Planning
Data to decisions
Assessment begins with a complete medical history, the chief complaint in the patient's own words, and vital signs. Know the 2017 ACC/AHA blood pressure categories: normal below 120/80; elevated 120–129 over below 80; stage 1 at 130–139 or 80–89; stage 2 at 140/90 or higher; hypertensive crisis above 180 and/or 120, which requires immediate referral and deferral of elective care. ASA classification runs I (healthy) through V (moribund); ASA III often requires medical consultation and modified treatment.
Examination includes extraoral and intraoral inspection with palpation of lymph nodes and a systematic oral cancer screening of all mucosal surfaces, periodontal charting, occlusion, caries detection, and appropriate radiographs and photographs as baseline. From these data you write a dental hygiene diagnosis (problem, etiology, signs and symptoms) that is distinct from the dental diagnosis, then a care plan with goals, interventions, expected outcomes, and reevaluation dates. Informed consent is an ongoing conversation, not a signature.
Traps: confusing the chief complaint with the diagnosis; omitting negative findings from the record; assuming a new patient's radiographs are current (exposures are individualized by risk and findings); and failing to consult the physician for an ASA III patient or uncontrolled hypertension.
Worked example: a 58-year-old with blood pressure 152/96, HbA1c 8.9%, and 6 mm bleeding pockets is classified as ASA II–III with stage III grade C periodontitis and high caries risk; plan physician consultation, defer elective surgery, provide nonsurgical therapy, and set a 3-month maintenance interval.