QUESTION: Legally, how often does a patient’s medical history need to undergo a comprehensive update?
ANSWER: There are no legal requirements regarding the frequency for updating medical histories; however, one of the most important components of a patient record is a current medical history. Determining an appropriate interval for updating is a matter of clinical judgment and should consider the patient’s health and history. Updates to medical histories may be accomplished by the patient filling out an additional form or by answering questions verbally. Patient responses should be documented in the original medical history or in a supplemental form specifically designed for updates. If a supplemental form is used, the patient should confirm the accuracy of the information and then sign and date the form.
How often you ask patients to complete a new medical history form depends on their individual needs. Common sense dictates that patients who have complicated medical histories need comprehensive updating more often than healthy adults. Asking patients to fill out a medical history form annually—unless a major medical change has affected their general health, at which point a new medical history should be conducted—is an example of a frequency protocol. The dentist should be informed when a patient presents with a new medical condition.
Many electronic dental records include medical histories that are easily updated at each visit. When using electronic records, practices often have patients fill out an initial medical history on paper. The American Dental Association (ADA) has an excellent resource titled “Dental Records,” which reviews this topic.1 The ADA’s recommendation is that patients should be asked at each visit whether their health status or medication use has changed. It should be documented that the patient was asked about changes to his or her medical history. Some practices have a policy requiring every patient to fill out a new medical history at certain intervals to maintain consistency between providers. While it is recommended that clinicians update patients’ medical histories at every appointment, determining the appropriate frequency for asking patients to fill out entirely new medical history forms is a professional decision—not a legal one.
- American Dental Association. Dental Records. Available at:raedentalmanagement.com/wp-content/uploads/2014/03/ADA-Dental-Records.pdf. Accessed November 3, 2014.
From Dimensions of Dental Hygiene. December 2014;12(12):74.