Amanda Waite, Case Manager at Dental Protection, looks at why a regular review of your patients’ medical histories and understanding their significance improves patient safety.
One of the first principles we learn at dental school is the importance of taking a detailed medical history before treating any patient. Most dental schools have their own designed medical history questionnaire, and this shapes the format, style and extent of any further questioning of the patient on particular points arising from their medical history.
Many practices, in similar fashion, use their own medical history questionnaires that patients are asked to complete when attending the practice for the first time. In most cases the design provides for the patient to answer “yes” or “no” to a set of predetermined questions, and then to sign and date the completed questionnaire. The dental practitioner then ensures that the patient has properly understood all the questions (for example, where patients leave one or more answers blank), and where “yes” answers have been given, further questioning of the patient will allow the details of any response to be clarified and expanded upon. Sometimes this highlights areas where further information needs to be gathered – perhaps contacting the patient’s medical practitioner (with the patient’s consent), or by asking the patient to bring a list of any medication they are taking along to their visit, so that the precise drugs and dosages can be identified with certainty.
When things go wrong
In several recent cases, the patient’s medical history has been at the heart of negligence claims brought against dentists and other dental team members. For example, a failure to take into account certain allergies to drugs (especially penicillin and other antibiotics), or to recognise the significance of long-term anticoagulants predisposing to postoperative bleedings, or the potential for drug interactions. Medications can also have side effects that cause visible changes in the soft tissue (phenytoin, calcium channel blockers and anti-retroviral for example).
Cases such as these often reveal that although a practitioner might have taken a comprehensive medical history when the patient first attended as a new patient, this process has either not been repeated or has been much more superficial, when the patient has returned for successive courses of treatment. In the majority of cases, no further written medical history questionnaire is ever undertaken, and indeed there is rarely any note on the record card to confirm what (if any) further questioning has taken place to update the patient's medical history.
This can be a considerable embarrassment when the patient has attended the same practice over a large number of years, and the practitioner is apparently still relying on the patient's original medical history details.
Medical histories change
It is self-evident that a patient’s medical history status is not static and indeed a patient's medication prescribed by others may change from visit to visit – it is prudent, therefore, to ensure not only those changes in medical history (including medication) are regularly checked and updated, but also that this fact is clearly recorded as a dated entry in the patient’s clinical notes. Guidance from the General Dental Council, Principle 4, states: “4.1.1 You must make and keep complete and accurate patient records, including an up-to-date medical history, each time that you treat patients.”1
Many dental practitioners take medical health histories verbally and if no positive or significant responses are elicited, an entry such as “MH – nil” is made in the records. While better than no entry, this approach carries the disadvantage that it can be difficult or impossible to establish precisely what questions were asked of the patient, in what terms, and what answers were given.
A well-structured health record questionnaire form, which is completed, signed and dated by the patient, and subsequently updated on a regular basis (ideally, during each successive course of treatment), is not only in the patient’s best interest, but is also the best platform for the successful defence of cases where failure to elicit or act upon a relevant aspect of medical history leads to avoidable harm to the patient. If there is doubt regarding a patient’s medical history, it may be sensible to defer treatment pending clarification of any areas of uncertainty. In all cases, the taking and confirmation of a medical history is the role of the dental practitioner and is certainly a key part of a dentist’s duty of care.
A patient visited a dental practice complaining of a sore gum. His regular dentist was off work sick on that day and the receptionist informed the associate of the problem.
The associate, who was under pressure as he was seeing a number of his colleague’s patients, saw from the record card that the patient had suffered from recurrent pericoronitis for a long time and took the view that an examination was not required. He passed a message via the receptionist that this was likely to be a recurrence of the same problem and provided a prescription for metronidazole.
Unfortunately, the patient’s medical history was not checked, and, in fact, he was on long-term warfarin therapy. The antibiotic potentiated the action of the warfarin and caused profuse bleeding when the patient accidentally cut himself while using a saw at home. This led to the patient being hospitalised and needing an emergency transfusion.
The associate sought advice and it was agreed that he would arrange to see the patient for review and explain the problems that could result from a prescription of this type of antibiotic, despite it being a drug commonly used to treat pericoronitis. This was an embarrassing discussion for the associate who apologised and assured the patient that he had learnt from this incident. The patient took no further action.
This case illustrates:
- The importance of a clinical examination to confirm that the prescription was a justified treatment and also the need for careful consideration of the patient’s medical history for possible drug interactions.
- The value of an apology when the patient has a poor experience.