Managing Professional Risks: Patient Records, Charting, and Documentation Protocols

Importance of Comprehensive Medical and Dental Health Histories

Your practice must ensure that a complete and accurate medical and dental health history is obtained for every new or active patient before any diagnosis or treatment is initiated. This critical step helps protect both the patient and the practice, providing valuable information that may influence treatment decisions and post-operative care.

Responsibility for Health History Collection and Review

Although a dentist may delegate aspects of the health history collection process to qualified staff, the ultimate responsibility for obtaining, maintaining, and reviewing current patient health histories remains with the dentist. This responsibility requires ongoing diligence to ensure records are both up-to-date and accurate.

Multi-Step Process for Managing Health Histories

Clearly communicate questions to patients to ensure understanding.
Encourage patients to seek clarification from the dentist or staff if any aspect of the form or its questions is unclear.
Verify that all required questions have been answered completely and honestly.
Obtain the patient’s signature to confirm the accuracy and completeness of the provided information.

Setting the Tone for Patient Relations

The health history form marks the beginning of the patient-practice relationship. It serves as a foundation for appropriate staff to fulfill their professional duties. The interactions between staff, dentist, and patient during this process are equally vital, as they contribute to a positive patient experience for both new and returning patients.

The Importance of Accurate Medical and Dental Health History

An accurate medical and dental health history is essential for providing safe and effective dental care. This information equips the dentist with valuable insights before beginning any treatment, particularly since certain medications may influence clinical decisions or impact post-operative care instructions. It is especially important to recognize that patients who are current or recovered opioid users might be hesitant to disclose this aspect of their medical history. Additionally, some patients may be reluctant to share that they are taking suboxone or other legal alternatives, such as methadone. If a complete history is not obtained from a new patient, or if an updated history is not collected from a returning patient, both the patient and the dental practice could be put at risk.

Completeness and Review of the Health History Form

To ensure patient safety and the integrity of the dental practice, every patient’s health history form must be thoroughly completed and reviewed, with documentation maintained in the patient’s record. It is also important to consider whether to accept patients who refuse to fill out health history forms or who intentionally provide inaccurate, incomplete, or dishonest information.

Key Elements to Include in a Health History Form

The patient’s health conditions and illnesses
Contact information for the patient’s primary health care provider and/or any specialists coordinating specific medical treatment
Current medications the patient is taking

Why This Information Matters

Certain drugs can interact with local anesthetics or other medications prescribed by the dentist
Some medications may affect dental treatments or impact other health conditions the patient has
Some drugs can influence post-operative care instructions

Additional Considerations

The specific reason(s) the patient is seeking dental care
Space to record additional information obtained during the dentist’s conversation with the patient

Reviewing and Updating the Medical/Dental Health History Form

After the patient completes the medical/dental health history form, it is essential for the dentist to thoroughly review the information before meeting with the patient. This step ensures the dentist is fully informed of the patient’s health background and can anticipate any areas that may require further discussion or clarification.

Prior to beginning any examination, diagnosis, or treatment, the dentist should discuss the contents of the health history form directly with the patient. This conversation is a critical part of the health history process, giving both the dentist and the patient an opportunity to address any points of concern, clarify details, and ensure the accuracy of the information provided.

During this discussion, the dentist should record any new details or additional information that emerges. These updates should be documented on the health history form to maintain a complete and current record.

The dentist should also be ready to respond to any questions the patient may have regarding the health history form. Since a single form may not cover every possible aspect of a patient’s health, the dentist may need to ask targeted follow-up questions that are specific to the individual’s health concerns.

Once the review and conversation are complete, both the dentist and the patient should sign or electronically sign the form. This step confirms that the information has been reviewed and agreed upon by both parties.

For new patients, the medical/dental health history form should be completed immediately before their first appointment. Active dental patients of record should be asked to review, confirm, and update their health history—including the list of current medications—at every appointment. Additionally, all patients of record should complete a new health history every two years. This process is designed to minimize the risk of overlooking recent changes in a patient’s health status.

Finally, it is recommended that dental practices consult with their professional liability insurance company and a qualified attorney to ensure that their procedures align with best practices and comply with relevant legal requirements for their location.

Active and Inactive Dental Patients of Record

A patient remains a “patient of record” unless the doctor-patient relationship has been formally terminated by either the dentist or the patient. It is crucial to document any efforts made to recall the patient and to note whether these efforts have been successful. Insufficient documentation about office policies and patient non-compliance can create risks, particularly when dealing with “non-active” patients.

Definition of Active Dental Patients

If there is uncertainty about which patients should be considered “active dental patients of record,” the American Dental Association (ADA) provides clear guidance. According to ADA policy:

Category I: Patients of record who have received dental service(s) from the dentist within the past twelve (12) months.
Category II: Patients of record who have received dental service(s) from the dentist within the past twenty-four (24) months, but not within the past twelve (12) months.

Patients who have requested that their records be transferred to another dentist or have indicated an intention to discontinue treatment—as substantiated in their records—should be excluded from the “active” patient category.

Each category of active patients of record can be further divided into:

New or regular patients: Those who have had a complete examination performed by the dentist.
Emergency patients: Those who have only had a limited examination performed by the dentist.

(Source: Excerpted from Active and Inactive Dental Patients of Record, Trans.1991:621; 2012:441)

Recording Health History Updates

It is essential to make a notation in the patient’s record indicating that the patient was asked about recent changes in health status or medications. This notation should include the date of the discussion and specify which staff member(s) initiated the conversation. The patient’s record should then be updated to reflect any new information provided.

Managing Patients Without Significant Medical History or a Current Physician

During the course of practice, a dentist may encounter patients who report no significant medical issues or who do not have a current physician. Such scenarios can pose considerable risk for both the dentist and the dental practice. For example, managing a hypertensive patient who does not have a current physician requires careful consideration.

Appropriate actions in these situations include:

Documenting physical findings, such as the patient’s blood pressure and pulse.
Recording the patient’s condition in the dental record and noting that the patient was encouraged to consult a physician.
Advising the patient that dental treatment must be postponed until their condition is managed by a physician, particularly when dealing with hypertension or uncontrolled diabetes.
Following up with the patient by phone or letter to request confirmation that they have seen a physician.
Considering dismissal of the patient from practice if they fail to seek medical consultation or treatment for their condition.

Dismissal of Patients

While deciding to dismiss a patient can be difficult, there are circumstances where it is the best course of action. It is important to recognize that dentists are not obligated to accept or treat every individual who seeks care at their practice.