Patients are often prompted to visit the dentist because they have been experiencing pain or discomfort.
Recording the details of the pain (as described by the patient) in a structured, detailed fashion is an important aspect of clinical record keeping and can be invaluable in assisting the clinician to reach an appropriate diagnosis and treatment plan, and in monitoring treatment outcomes.
One of the advantages of keeping careful and detailed records of a patient's pain history is that it highlights significant changes and developments in the features of the patient's symptoms which can, in turn, lead the clinician to the correct diagnosis. The ability to make comparisons from one visit to another, places the clinician in an better position to assess the effect of any treatment that has been carried out.
Dental nurse
You may find it helpful to get your dental nurse/chairside assistant involved in this process. They can help to ensure that all key conversations are properly recorded and that no important information is overlooked.
The complete picture
Even an experienced clinician can sometimes be misled by the way in which a patient describes the symptoms they are experiencing. It can be tempting, especially under extreme pressure of time, to leap to a diagnostic conclusion based upon the first few things that a patient says. By failing to elicit other details of the patient's pain, one can miss glaring inconsistencies in the overall picture, which might provide a clue that all was not as it had seemed initially.
Asking questions
Three types of questions are particularly useful when asking patients about pain they have been experiencing.
1) A closed question can usually be answered with a simple 'yes' or 'no'. For example 'does the tooth hurt when you put pressure on it?' or 'Have you been taking any painkillers?'
2) An open question cannot usually be answered with a simple yes or no. Open questions tend to begin with What? When? How? Why? Which? And so on. For example 'Which tooth do you think the pain is coming from? What does the pain feel like?' or Can you describe what the pain feels like?
3) Shopping list questions. Here you give the patient a range of options from which to choose. For example 'Is there anything particular that makes the pain start? For example, hot things?...Biting on the tooth etc.' Or 'Can you give me an idea of how the pain feels - is it a short sharp pain, or a full ache - or a throbbing pain perhaps?'
Open questions will normally yield the greatest and most detailed information although a combination of open and closed questions is usually required. Shopping list questions can sometimes be used to save time, especially when dealing with patients who are not very forthcoming in their answers.
Audit exercise
- Select ten patient records at random, for patients who have recently attended in pain or discomfort (a likely source of this might be patients who have recently attended as an emergency).
- In each case, assess the level of detail that you have recorded in respect of the patient's pain. You may wish to use a scale such as:
0 = not recorded at all.
1 = recorded in some way, although no detail.
2 = recorded with reasonable detail.
3 = full, detailed record.
- Apply this scale to each of the ten criteria described in the Panel to provide a possible maximum score of 300 (10 X 10 X 3). Note your baseline score. Depending upon how you tend to ask/record questions and the patient's responses, there will be a varying degree of overlap/duplication across the ten criteria which are suggested here simply for guidance.
- Produce a checklist to remind yourself of the ten keys points when you are treating patients with pain/discomfort during the next few months.
- Repeat the above exercise and compare your new score with the baseline to measure your improvement. Identify any aspects where further improvement would be beneficial. Checklists are helpful enabling a process to take place. A process is a systematic way in which a certain activity is carried out consistently and to a specific standard. Processes make it less likely that errors will occur.
Ten key criteria to consider when recording pain
History
Has the patient experienced the pain before? Or is it the first time?
Duration
How long has the current pain been present? Does it come and go, or is it persistent?
Onset
What tends to bring on the pain? (For example, hot/cold food and drink, breathing in, bending down, physical activity, chewing etc).
Site
Where is the pain? It is sometimes helpful to ask the patient to point to where they feel the pain (eg. to a specific tooth). It is just as important to record the fact that a specific tooth has been identified as being the likely cause of the pain.
Nature
Get the patient to describe the pain - preferably in their own words. Does it seem to come from anywhere specific, or is it vague and diffuse? (Open questions can be particularly useful here).
Type
Is it a short, sharp pain? A dull ache? A throbbing pain? A combination of the above? Is it a surging pain?
Pattern
Is it worse at mealtimes? Does the pain change during the day (for example, is it worse at night, or in the morning?) Does lying down/sitting/standing up make any difference?
Moderating factors
Does anything make it worse? Does anything help to relieve the pain or make it better?
Referral
Does the pain stay in the same place or does it seem to radiate elsewhere? Is the pain being referred to any other structures (the eye, the ear?), or other parts of the mouth or face?
Severity
Pain is of course highly subjective and different patients have different thresholds/tolerance of pain. But it can still be helpful to get an indication of how severe the pain is from the patient's perspective. It can sometimes be helpful to ask the patient whether the pain has prompted them to take any analgesics and if so, what type/what dose/how many/how often. This history may also be important in moderating the level of pain being felt by the patient and reported at the time of the examination.