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Exercise in risk management:
the medical history
Busy practitioners often comment
that they are overwhelmed with risk
management advice, but never
have enough time to apply it. This
continuing series distils key messages
from a specific area of risk and
provides the dental team with
practical tools that can make a real
difference right away.
Introduction
Most practices and other clinical
settings will routinely use a written
medical history questionnaire,
whereby any new patient is invited
to answer yes or no to a series of
specific questions regarding their
medical history. This form is usually
signed and dated by the patient, and
the dentist will then go through the
questionnaire with the patient, to elicit
further details of any yes responses,
either adding these to the
questionnaire itself, or making
additional notes in the clinical records.
Unfortunately, this excellent start is
often undermined by a failure to
update this initial medical history
when subsequent courses of
treatment are undertaken. Indeed,
many years will often pass before
there is any further reference to the
medical history in the clinical notes
at all, and this can lead to a variety
of problems.
Updating
It is important that the patients
medical history is always kept up-to-
date, and unless a specific routine is
consistently followed in order to
achieve this, a patient may not think it
worth mentioning something which
could prove to be critical.
Checking any medication that the
patient may be taking is an important
part of this process. In the elderly,
or those with certain medical
conditions, the patient may be taking
a variety of medications that may have
the potential to impact upon their
dental care. Furthermore, the drug
regimen (and dosages) may well be
changing on a regular basis.
Sometimes, an awareness of any
medication being taken regularly,
provides a clue to a change in the
patients medical history that might
not have been volunteered,
particularly if the patient is
embarrassed by the condition and/or
does not see any relevance to their
dental care and treatment. A good
example of this is a patient taking
certain forms of oral contraceptive,
which can be rendered ineffective by
the administration of broad-spectrum
antibiotics.
It is a matter of clinical judgement in
the circumstances of each individual
case, how often the updating of the
patients medical history should take
the form of a further written
questionnaire, or whether it is
sufficient for it to be done verbally.
If the latter, the discussion should in
any event be confirmed by means
of a dated entry in the clinical records.
A compromise solution would be
a supplementary sheet, or even a
rubber stamp on the reverse of the
original medical history form, to the
effect that the patient has read the
previous responses to the medical
history questionnaire, and confirms
that this information is still correct.
This should again be signed and dated
by the patient.
Dentists and other members of the
practice team should resist the
temptation to complete the yes and
no answers on the patients behalf,
to avoid the suggestion that they
might have incorrectly recorded the
patients actual responses. Wherever
possible, the patient (or parent) should
complete the questionnaire
personally.
Computers
Many computerised practices
strenuously avoid the creation and
storage any paper documents, and so
a clinician will often take a medical
history verbally, perhaps using screen-
based prompts and entering the
patients responses on screen. This
again invites the suggestion that the
patients responses were incorrectly
recorded. It is more sensible to take a
written medical history, this being
signed and dated by the patient. This
document could either be retained in
its original form, or alternatively could
be scanned into the patients
electronically held file.
Audit
Select 50 record cards at random, and
carry out an audit to measure how
much of the information outlined in
the panel you have captured, and
how recently it has been formally
confirmed as being correct. Repeat
this exercise at appropriate intervals.
Action and follow up
Starting tomorrow, establish a routine
when preparing a day list for the
next days patients whereby your
reception/administration team
identifies which patients do not
have an up-to-date medical history,
including all the above details. The
patients concerned could then be
asked to complete a new medical
history questionnaire on arrival for
their next appointment, or
alternatively the dentist can do this
with them verbally. Clinical staff could
routinely perform similar checks in the
surgery, providing a further layer of
protection.
Summary
Keeping up-to-date records of a
patients medical history is an
essential part of the duty of care.
Involve every member of the practice
team and let your patients appreciate
the attention to detail and concern you
show for them, and of the quality of
care you are providing for them.
Clinical notes should contain the
following
The patients full name
The patients date of birth/age
The patients correct contact details
(including address, work, home
and mobile phone numbers in case
you ever need to contact them in
an emergency).
Remember that all of the above
details may have changed since you
last saw the patient. Check regularly
that all this information is up to date.
The patients e-mail address (if the
patient has agreed that you may
contact them by e-mail). One of the
advantages of this is that email
addresses tend to change less
often than other contact details.
Yes or no answers to a
comprehensive list of medical history
questions. These questions should be
worded in terms that the patient is
likely to understand. This is particularly
important when a patients first
language is not one normally used
at the practice.
Details of the patients current
medication (incl. dosages).
The date when the medical history
was last taken or checked.
The patients signature (or when
signed on the patients behalf, the
identity of the person making the
statement).