Patient Records
Vital Signs
Chapters 26 and 27
Privacy Policy
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HIPAA
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
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
Patient Registration Form
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Patient Info
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Name, DOB, address, email address, telephone
numbers, employment info, spousal info and
emergency contact.
Insurance information

Company name, employee, address and phone
number
Patient forms cont.
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Responsible Party
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Person responsible for payment
Signature and date
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Patient verifies the accuracy of info
Temperature
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Average 98.6o F
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Range
Rectal
Axillary
97.6o F --- 99.6o F (o)
+1 degree F -- Highest reading
-1 degree F
TERMS
100o F and above

Pyrexia
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Hyperthermia 103o F and above
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Hypothermia
94o F and below
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Electronic
fastest reading

Oral glass
3 minutes
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Rectal
most accurate
Factors that affect Temperature
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Eating, drinking, smoking wait 15 min.
Time of day-- lowest in AM, highest in PM
Environmental
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Low in winter, high in summer
Age of person– low in elderly
Physical activity—low at rest
Emotional activity—high with anxiety
Disease condition—high with fever to fight
infection
Pulse

Average--
72 beats per minute

Range-- 60 – 90 beats per minute
Terms

Bradycardia-- 60 and below
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Tachycardia-- 100 and above
Characteristics
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Rate-- speed (normal, bradycardia,
tachycardia)

Rhythm--
regularity (regular, irregular)
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Volume-thready)
fullness (weak, bounding,
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Radial pulse
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Most common pulse point
Factors that affect pulse
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Exercise
Stress
Elevated temperature
Drugs
Illness
Sex (male or female)
Procedure

Review the procedure on how to measure
pulse


Count pulse full minute, hold pulse
Count Respirations full minute and record
Respirations
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Average--
18 breaths per minute
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Range-- 12 – 20 breaths per minute
Terms
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Accelerated-- 25 and above
Tachypnea-rapid or shallow breathing
Dyspnea--difficult or labored breathing
Apnea-- period of no respirations
Cheyne-Stokes--period of dyspnea followed by apnea
Stertorous - snoring like respirations
Rales-- moist respirations “death rattle”
Review procedure
Blood Pressure

Measures the force of the blood against the
walls of the arteries

Average--

Range-- 100/60 – 140/90
120/80
Terms

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Hypertension-140/90 and above
Hypotension-- 100/60 and below
Systolic-first sound of blood pressure,
when heart contracts
Diastolic-last sound, when heart
relaxes
Blood pressure is measured over the Brachial
artery
Factors that affect blood pressure
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Sex of patient
Exercise
Stimulants (smoking due to nicotine)
Stress
Hereditary factors
Obesity
Procedure

Review steps for taking blood pressure
Examples
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140/86 – 101.6o F – 90 – 20
pyrexia
154/94 – 99.2o F - 88 – 16
hypertension
80/40 – 98.2 F – 112 -20
tachycardia, hypotension, shock
132/78 – 98.6 F - 44 -14
bradycardia
Terminology
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Prefix
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High/fast
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Hyper—
Tachy-
Low/slow
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HypoBrady-
Dys- difficult/painful, ie dyspnes
A- without, ie apnea
Terminology

Suffix
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Thermia (temperature) ie, hyperthermia
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Cardia (pulse, heart rate) ie tachycardia,
bradycardia
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Pnea- (respirations, breathing) ie apnea
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Tension (blood pressure) ie hypotension