Hygiene Atlas

Atlas · Plate XII · Patient Assessment and Charting · 01

Medical history and vital signs

Review and update the health history, medications and allergies at every visit. Anticoagulants, bisphosphonates and immunosuppressants may call for a medical consult or a change in care, but only the prescriber stops a drug. Elective care is usually deferred when blood pressure reaches about 180/110, and patients on drugs that cause orthostatic hypotension should sit up slowly.

High-yield facts · 6

  1. Review and update the medical history at every visit, including medications, allergies and recent changes.T2
  2. Patients on bisphosphonates, anticoagulants or immunosuppressants need consults or modifications.S57S67
  3. Routine dental cleaning can proceed for warfarin patients when the INR is in range (usually under about 3.5 for minor procedures); check a recent INR.S57
  4. Do not tell patients to stop antithrombotic drugs; the prescriber decides.S57
  5. Blood pressure: elective care is usually deferred at 180/110 or higher (some sources use 180/120), with medical referral. (verify office threshold)S27T2
  6. Patients who take medications that cause orthostatic hypotension should sit up slowly.T2

Facts are written in our own words; each tag links to its source. Values marked "sources vary" differ between references, so check the one your program uses.