Medical History Updates
How often should patient medical histories be updated? Below you will find some helpful tips for obtaining and keeping an up-to-date patient medical history. At a minimum, at least every year, ask the patient to look at the last medical history form they completed and ask if anything has changed on that form. However, a more timely protocol may be better.
A patient’s medical history should include, at a minimum:
- Current and past medical conditions
- Surgeries and hospitalizations
- Current and over-the-counter medications
- Herbal supplements
- Drug allergies
- Blood pressure and pulse
- Emergency and physician contact information
Keeping a patient's medical history current is essential because it supports proper care and can prevent dangerous complications.
An Accurate, Complete, and Current Medical History
The treating dentist's fundamental duty is to obtain an accurate, complete, and current medical history before treating a patient. Without this, you cannot adequately protect the patient and yourself from unnecessary risks. When obtaining a patient’s medical history, the first question to ask your patient is: when was the last time you had a complete physical exam conducted by your medical doctor? If any high-risk procedures are anticipated, you may want to request that they get a physical exam before starting treatment if they have not had one in three or more years.
Also, if your assessment of the patient’s health (noticeably out of breath after a short walk from the waiting room to the operatory) contradicts what may be indicated on their health history form, request that the patient obtain clearance from their physician before delivering treatment.
Review Medical Histories Regularly
Safe dentistry depends upon always having the most current information about your patient’s health. It is always recommended to review their medical history before beginning a course of treatment, especially patients with a complicated history.
The following steps should be taken at every visit preceding a course of treatment and the more risk involved in the treatment, the deeper the inquiry should proceed into their current state of health.
- If available, review the most current written medical history form in their chart with your patient.
- Ask your patient, “Have there been any changes in your medical history since your last visit to our office?”
- Check the patient’s current dietary supplements.
- Ask the patient if, since their last visit, they have seen a medical doctor.
- Ask if there are changes (new dosages), and are they taking any new prescription medications?
- Have they suffered any illness or injuries, particularly those requiring medical attention?
- Has their medical doctor informed them of any contraindications and precautions before receiving dental treatment?
Any affirmative responses or changes in medication or supplement regimens should be noted in the patient’s treatment notes and researched regarding their influence on a proposed course of treatment. If they wish to advise you of any updates, you should enter them in the treatment notes and mark them on their current health history form, asking the patient to initial and date them.
It's important to obtain an accurate and complete medical history from the patient. Without it, you may be opening yourself and your patient to unnecessary risks.
Disclaimer: The information contained on the DentistCare Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. All information contained on the blog is subject to change.
