24 November 2009

Q. My dentist consistently omits to check the medical history form or get the patient to sign it. I have asked him to do this and on many occasions have undertaken to go over the medical history and get the patient to sign it prior to treatment myself. The dentist says that it does not matter when the medical history form is signed as long as it is during the course of treatment. He recently prescribed a course of antibiotics to a patient that was, according to the MH, sensitive to this particular antimicrobial. The patient was extremely annoyed and he has asked me to back him up in a complaint to the GDC. What should I do?

Current guidance is that a full medical history should be recorded at the very least on an annual basis. Much depends on the patient and their state of health, and in some situations more frequent medical histories may be required. The medical history does not necessarily have to be undertaken by the dentist but may be checked with the patient by a suitably trained member of the dental team. The overall responsibility is that of the treating clinician. Medical histories should always be checked before prescribing any drugs. The patients signature can be helpful, but is not necessarily required provided the records demonstrate that the medical history was checked. It would be good practice for any treating clinician to review the medical history for accuracy and record any changes at each patient visit. Any concerns can be discussed with the patient and raised with the referring dentist if necessary.

It is understandable for a patient who is sensitive to an antibiotic to be annoyed if it is prescribed for them, albeit in error. Thankfully in this situation the patient was not harmed although the potential was always there. You do need to be very careful when discussing this matter with the patient. You may not know all the facts and a poorly thought through remark will certainly not be helpful to either party. By all means sympathise and perhaps agree that it was fortunate that no harm occurred as it was recognised in time. Encourage the patient to raise his concerns initially at a personal level with the dentist. If he remains dissatisfied after this then he could still take the matter further if he felt it appropriate to do so. You could point out that there are options other than the GDC in this regard.

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