Knowing a patient’s full medical history is an important tool in the care and management of dental patients. This isn’t something to skim over. A patient’s medical history (including family history) contains relevant information on his/her overall health; something you do as dentist can exacerbate or complicate a patient’s medical condition or conflict with one or more of the patient’s medications, dietary supplements and/or drug use/abuse.
All medical events (any problems a patient has experienced) makes up a complete medical history. You should obtain a complete medical history for each patient you see in your practice. Further, their medical history should be updated periodically (regularly) and must be updated prior to administration of any (all) medications including anesthetics and/or sedatives.
So, what does the medical history review include? What should you indicate on the patient’s medical record?
- A complete medical history should include:
- Information on three generations of relatives
- parents, siblings, children, grandparents, aunts, uncles, nieces, nephews, and cousins.
- A list of current medications: prescribed and over the counter (licit and illicit)
- Any known medication allergies.
- Past hospitalizations.
- Significant surgeries.
- Lifestyle habits (and doc, sometimes you have to be extra observant and diligent because not everyone is forthcoming about something they consumed in the parking lot before walking into your office).
Ask yourself this... are you gathering a complete medical history
for your patients? Are you taking the full history into consideration when developing a treatment plan?
When you have a complete patient medical history, you’re better able to identify at
risk patients for common disorders such as heart disease, stroke, diabetes, certain cancers, and medication conflicts. All of these help dictate the treatment plan you wouldn’t prescribe controlled
substances to a patient with a history of drug abuse, patients with cancer undergoing/taking chemotherapy medications may not be able to receive nitrous oxide, diabetics are more prone to periodontal disease.
On a patient’s initial visit, a complete medical history must be obtained and updated annually AND reviewed at every visit, before inhalation sedation, moderate sedation, deep sedation, or general anesthesia with updates as necessary. This is critical. The medical history of your patients is a part of their permanent medical record. For patients over the age of 21, it’s required
for providers to maintain medical records for a minimum of five years from the date of last treatment received. For patients under the age of 18, medical records must be maintained until age 21 or a minimum of five years from the last treatment date.
As an outstanding and respectable healthcare professional, you owe it to your patients (as well as your reputation) to provide them with the best possible care you have to offer. Maintaining an extensive and complete medical history is an essential step to achieving this goal.
About the Author
A former Law Enforcement Officer/ Dental Board investigator, Duane Tinker is the CEO of Dental Compliance Specialists. Mr. Tinker provides compliance consulting, auditing and training services for dentists and Dental Service Organizations on compliance risks including OSHA, HIPAA, Dental Board rules/ regulations, state radiology rules, DEA and state drug regulations, and Medicaid. Mr. Tinker is a frequent speaker for dental societies and study clubs. He also hosts a podcast called Talking with the Toothcop. Mr. Tinker can be reached by calling (817) 755-0035 or through his company’s website DentalCompliance.com.