Healthcare considerations and wellness trends are ever-changing, and your record of patients’ health histories should be keeping up. From GLP-1s and supplements to mental health awareness leading to formal diagnoses and medications, a patient’s unique health information can significantly influence your treatment decisions.
Maintaining complete and up-to-date health records mitigates safety and legal risks. CDA’s analysts recommend that patients review and update health history forms at every visit and complete a new form at a regular frequency.
Risky business: The potential liabilities of out-of-date or incorrect health forms
Let’s say one of your patients of record walks into your practice this week. To the naked eye, nothing about them is different, but their health status could have changed since their last visit. A new pregnancy, a mental health struggle, a diagnosis or a new medication are all impactful changes that may not be immediately apparent.
Failure to document updates at every visit could mean you miss critical, treatment-altering information and open yourself up to potential claims or complaints.
Patients rarely inform their dentist of changes to their health without being prompted. Proactively collecting health information from patients and having processes in place to update health forms at every visit ensures that important updates are not overlooked.
‘Do I have to do this?’ How to handle patient pushback
Even when sound protocols are in place, some patients may resist or outright refuse to update their health history forms. They may say, “I filled this out last time” or “That’s personal, I’d rather not share that information.” If this happens, pause to explain the importance and necessity of accurate, complete and current health information.
Consider one of the following sample responses to patient pushback:
“I understand that filling out forms is tedious, but for us to safely treat you, we need you to confirm if your health history has changed. Especially if you are taking any new medications.”
“Our office policy requires an updated health history for our records before we can begin treatment. Please review the previous form and note any changes.”
“Even if nothing has changed, please review and sign the form. Our office policy requires an updated health form for your safety.”
If a patient continues to refuse to provide a complete or updated health history after this conversation, dismissal from the practice may be warranted.
Resources
CDA members can sign in to access sample health history forms as a benefit of membership. Just as patient health changes over time, the required fields and information requested on your forms should be adapted over time to fit the needs of your practice.
Think you’ve got the do’s and don’ts of health history forms down? Take this three-question Practice Health Check to test your knowledge.