21 February 2012

Do I need to take a new medical history every time I examine a patient?

The current guidance from the GDC and from the Faculty of General Dental Practice of the Royal College of Surgeons of England is that a patient’s medical history should be checked and updated at every treatment visit.

In practical terms it is good policy to take a full medical history every time a patient is examined and the use of a medical history pro forma provides an excellent way of recording this information.

It is important however that the patient is not left to complete the medical history form themselves; but for whoever is carrying out the examination to go through all the questions with the patient to ensure they fully understand them or indeed can actually read the question.

Such questioning should obviously be carried out in a manner that ensures patient confidentiality. If a practice wishes to become paperless then the medical history pro forma can scanned onto the computer. If you wish to dispose of the hard copy, it should be destroyed by shredding or incineration.

When a patient attends for an appointment as part of a course of treatment it is always worth checking to ensuring that they have not started on any medication or have suffered any relevant illnesses since their last visit. Some practices encourage patients to volunteer such information by placing a sign in the waiting room requesting patients to inform their dentist of such changes.

Taking a full medical history at each examination can be onerous but it is certainly worthwhile in protecting the patient and the dentist’s own position. By having a written record of the patient’s medical history, and indeed signed by the patient, often affords protection to the dentist. Particularly if an allegation is made that s/he has not taken the patient’s medical history into consideration when carrying out treatment which subsequently resulted in the patient being avoidably harmed.

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