“Don’t carry the past into your present” might be the favorite mantra of motivational speakers, but it is bad advice for healthcare settings. Safe, effective and personalized dental treatment begins with a comprehensive understanding of your patient's medical and dental history.
An accurate, up-to-date and comprehensive health history gives dental practitioners the data they need to make informed treatment recommendations and respond appropriately, which is especially critical in the event of an adverse occurrence. One call to The Dentist Insurance Company’s Risk Management Advice Line illustrates the risks of an out-of-date health history.
Outdated Health History: A Case Study
After a routine dental exam and cleaning, a patient fell down the stairs outside his dentist’s office. Alerted to the scene by other patients, the dentist found his patient lying on the ground where the patient appeared to be unconscious and snoring. When he regained consciousness, the patient was alert but unable to answer basic questions with any certainty.
Staff members called paramedics who quickly arrived and took the patient to the hospital where he was eventually admitted. Meanwhile, the emergency department contacted the dental office and asked for some of the patient’s information for intake. Specifically, an emergency contact was needed, as the patient remained unable to provide any detailed information. In reviewing the patient’s health history form, the dentist noted that the area provided for an emergency contact had not been completed by the patient. It was left blank, but staff had noted that the patient “lived by himself.”
Concerned that he might be held liable for the patient’s fall or being unable to provide an emergency contact, the dentist called TDIC’s Risk Management Advice Line. An analyst was able to offer direction for both reporting an adverse occurrence to the state dental board and for updating the practice’s health history forms.
How to Obtain and Maintain Accurate Patient Health Histories
California Dental Association members can log in to cda.org to download sample health and dental history forms. You may designate a practice team member to help patients complete or update their medical and dental health history forms. However, understand that, as the dentist, you are responsible for reviewing each patient’s health history forms to ensure they are as accurate as possible.
The health history form should be completed by each new patient or the new patient’s legal guardian. TDIC advises that the patient (or the legal guardian if the patient is a minor) review, update and sign a health history form at every appointment or at least every six months. A new form should be completed every two years by active patients. When minor patients turn 18, a new form should be completed by the patient. Updated forms should be attached to the previous forms and all versions of the forms should be kept as part of the patient file.
Reviewing the form should be an interactive process between the patient and dentist at the beginning of every visit. This provides an opportunity to address any concerns or questions about details disclosed on the form, in addition to confirming that important information was not omitted. When reviewing the health history, take time to question the patient regarding any areas of concern or speculation. Write clarifying comments on the health history form along with the date of the discussion. Upon completion of review with the patient, the form should also be signed and dated by the dental provider.
As part of the review, be sure to discuss emergency contact information and with whom the patient has authorized you to discuss their care. Recognize that the relationship status of an emergency contact can change, leaving the patient with outdated information on file. Verify the accuracy of these designated contacts at each visit.
Risk management analysts have identified six ways that maintaining accurate health histories protects your patients and practice:
1.Prioritizing Patient Safety
Dental treatments, even routine ones, can have significant implications for patients with certain medical conditions or allergies. By meticulously collecting and updating health histories, you can identify potential risk factors and adapt your treatment approach accordingly. For instance, a patient on blood thinners might require special considerations during oral surgery to prevent excessive bleeding. Without this critical information, you risk compromising the safety of your patients.
2. Legal and Ethical Responsibility
Maintaining accurate health records is not simply good practice; it's a legal and ethical obligation. In the event of complications or patient complaints, thorough documentation can serve as a crucial defense. Moreover, it demonstrates a commitment to transparency and accountability, which are essential for building trust with your patients.
3. Tailored Treatment Plans
No two patients are alike, and their oral health needs can vary significantly. By understanding a patient's medical history, you can craft treatment plans tailored to their specific needs. For example, patients with diabetes may require more frequent checkups to monitor gum health, as they are more susceptible to gum disease. These customized plans not only enhance patient outcomes but also demonstrate your commitment to their well-being.
4. Medication Interactions and Allergies
Many patients are on medications that can interact with dental treatments or influence their recovery. Without an accurate medication history, you may unknowingly prescribe treatments that could have adverse effects when combined with a patient's existing medications. Similarly, allergies to dental materials or anesthesia can lead to serious complications if not properly documented. A thorough health history helps to avoid such pitfalls and ensure patient safety.
5. Uncovering Hidden Health Issues
Dental health is intricately linked to overall health. Certain oral conditions can be indicators of systemic health problems, such as diabetes, cardiovascular issues, substance abuse or autoimmune disorders. By reviewing health histories, you may identify these red flags early on and recommend further evaluation or consultation with other healthcare professionals. This proactive approach can lead to early diagnosis and better management of a patient’s underlying health conditions.
6. Strengthening the Dentist-Patient Relationship
A strong dentist-patient relationship is built on trust, communication and mutual respect. Taking the time to gather and update health histories demonstrates care for your patients' well-being. It fosters open dialogue and allows patients to feel more comfortable discussing their health concerns with you. This, in turn, leads to better collaboration and more successful treatment outcomes.
Obtaining and regularly updating medical and dental health histories for every patient is a cornerstone of ethical and responsible dental care.
When in doubt about documentation or navigating other practice challenges, reach out to TDIC’s Risk Management Advice Line for guidance.
TDIC’s Risk Management Advice Line is a benefit of CDA membership. Schedule a consultation with an experienced risk management analyst or call1.877.269.8844. Reprinted with permission from the California Dental Association, copyright November 2023.