Some questions may be seen as an invasion of privacy. Most people don't trust healthcare providers until trust is earned. This is especially the case with so much misinformation that was created during the COVID-19 crisis. Earning trust entails spending time with patients and informing them why you need to build an accurate, complete patient history.
Dr. James V. Anderson
It's important to note that the patient's interaction with the staff and the dentist during the process of recording and reviewing one's health history is at least as imperative as the information listed on the form. This process sets the tone for a positive patient experience for both new patients and active dental patients and patients of record who haven't been in lately.
An accurate medical/dental health history is necessary to acquire before beginning treatment. Safety precautions indicate that certain medications can influence treatment decisions or impact postoperative care instructions, putting the patient, and the practice, at risk.
The health history form
All patients' health history forms must be completed, reviewed, and recorded into the patient's chart. Some of the issues covered in a health history include the patient's health conditions and illnesses.
Be sure to ask patients about the following:
- Current and past medical conditions, including whether the patient has (or has had) an infectious disease (COVID-19), a blood disorder, asthma, allergies, osteoporosis, and dysfunction involving an organ (e.g., diabetes, kidney, or heart disease, etc.)
- Surgeries, some of which may require prophylactic antibiotic dispensing before dental procedures
- Current prescribed and over-the-counter medications, recreational drugs, botanicals, and herbs. Different types of medications may interact with local anesthetics or other drugs the dentist may prescribe and may affect other health issues. Some drugs may impact postoperative care instructions.
- Known allergies, including allergies to anesthesia (epinephrine) and latex
- Current medical treatments, e.g., chemotherapy
The above is not a complete list. The ADA has guidelines for creating a medical/dental health history form, and it offers sample forms, which are available in English and Spanish as well as for children and adults.
The patient conversation
Completing the form is only one step in the process of taking a patient's health history. After the patient has completed the form, the dentist should analyze the form before meeting with the patient.
The dentist should then discuss the contents of the health history with the patient before initiating any examination, diagnosis, or treatment. The conversation is an essential element of the health history process and helps build a bond between the dentist and the patient. Be prepared to answer any questions the patient may have about the form and their health history.
The dentist should then record any new details or vital facts on the health history form. Finally, both the dentist and the patient sign or e-sign the form once the review and discussion are over.
Make a note in the patient's chart that indicates the patient was asked about current health and medication changes. The notation should include the date of the discussion and which staff member(s) initiated the conversation. The dentist or team member should then update the record to reflect the new information.
All patients should be asked to complete a new health history form every two years. Although patients may balk at the request, confirm and update their medical/dental health history records, including the list of current medications. This process can significantly reduce the possibility that a patient will neglect to inform the dentist and staff of recent changes to their health.
For additional help, consider consulting your professional liability insurance company and a qualified attorney for their recommendations about how you can ensure compliance when it comes to this issue.
Connecting with patients about their health should always be done with the best intentions for the well-being and safety of your patients. With patience and understanding, your patients will acknowledge the extra efforts you and your staff are taking to keep them safe.
Dr. James V. Anderson is a practicing dentist in Syracuse, UT, and is the CEO and founder of eAssist Dental Solutions. He can be reached via email.
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