10.26.12 Issue #555 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter
 


Belle DuCharme, CDPMA
Instructor/Consultant
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Are You Updating Patient Health History Forms?
Belle DuCharme, CDPMA

Dear Belle,

“My husband was up all night bleeding from his mouth from an appointment to prepare two teeth for crowns. He is a heart patient with an artificial valve and is on Coumadin.  

His tongue and cheek were cut by dental instruments and they could not stop the bleeding but sent him home anyway. He said they never asked if he was taking the Coumadin but asked if he was taking aspirin. He is seeing his physician today. Is this right?”  

Worried Wife

Of course this scenario is not right, and sadly it happens too often in dental practices. Carelessness in updating patient medical histories leads to incomplete record taking and possible injury to patients. An accurate and current medical history is an essential tool in providing excellent dental treatment. Protecting both the patient and the dentist from unnecessary risks requires a written medical history to provide information to accomplish the following:

  • Identify medications to prevent drug interactions and possible side effects
  • Identify any oral manifestations of systemic disease or pharmacotherapy
  • Identify and manage patients with compromised medical conditions such as heart disease, high blood pressure and diabetes
  • Identify patients using substances that interfere with healing such as tobacco and alcohol
  • Identify patients that may have eating disorders or other behaviors affecting dental health
  • Identify patients that have had implants such as knee and hip replacements
  • Identify patients undergoing chemotherapy
  • Identify patients with back or neck problems so that they can be made more comfortable
  • Identify any new allergies such as latex
  • Identify patients that are developing symptoms of a disease
  • Identify and verify the need for pre-medication

Failure to obtain, update and investigate each patient’s medical history is a basis of negligence and has been the root in alleged professional liability claims against dentists. The following steps should be taken at every patient dental visit:

  • Review in private the written history
  • Ask the patient if there has been any changes in their health or medications since the last visit to the dental office
  • Have they suffered any injuries or illnesses since the last dental visit
  • Confirm the current medications and dosages including dietary supplements
  • Note any changes in the patient’s computer chart and paper chart (both must match if you are maintaining both types of records)
  • Visually assess the patient for any remarkable changes since the last visit such as loss of weight/weight gain or psychological stress such as loss of job or death in family
  • Have the patient sign and date the update or a new health history if there are several changes or if you have a new health history form
  • Staff member taking the information must sign and date also

All staff should be trained in checking medical alerts for patients in both computer and paper chart records. The information should be displayed clearly so that all providers are aware of the patient’s conditions. Using paper charts? Do not write history on the front of the chart. Put a red medical alert tag on the patient’s record which will warn the viewer.

During the morning business meeting the clinical staff must review each and every patient for medical alerts and possible complications to treating each patient. Who is responsible for the task of updating medical records? The dentist is ultimately responsible for the diligence in protecting patients from risks of harm, but other staff members are not immune from discipline. In many offices this task is considered a clerical or administrative task. It is when asking the patient for the information, but it is the clinical provider’s duty to investigate and understand the ramifications of the history in relationship to the dentistry that will be delivered to the patient that day. 

Presenting treatment plans to patients is also a good opportunity to check medical histories. The patient will be required to sign informed consent forms that let the patient know what to expect before, during and after treatment. Medical histories, drugs and supplements are verified to make sure there will be no unfavorable interactions during treatment.

The American Dental Association has the latest information on what questions should be asked on health history forms. The uniformity and consistency of this system is paramount to the protection of the patient and the dental providers. Make it a priority in your practice, not an afterthought.

Take your practice to a higher level of professionalism by enrolling today in a McKenzie Management Dental Business Training Program.

If you would like more information on McKenzie Management’sTraining Programs  to improve the performance of your team, email training@mckenziemgmt.com

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