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Importance of Medical Histories

During my review, I was penalized for taking too much time on medical histories. I am concerned that if I am not thorough, I may be liable if something goes wrong.

During my review, I was penalized for taking too much time on medical histories. I am concerned that if I am not thorough, I may be liable if something goes wrong.

Performance reviews play a critical role in the development of dental office personnel. They provide an opportunity to discuss what staff members have done well, what areas can be improved, and what should be implemented to foster such improvements. However, when employers voice areas of concern about performance, employees often respond defensively without considering the cause of the criticism.

One such example is a scenario where the dental hygienist is penalized for taking too much time on medical histories. Dental hygienists are dedicated to providing excellent patient care with great attention to detail. This care includes updating the medical history at each recare appointment, or completing a new medical history if the previous one is outdated.

The consequence of this practice is two-fold. First, it can cause the dental hygienist to run behind schedule and, second, patients who do not understand the significance of the medical history for dental procedures may become irritated about updating their medical history at each recare appointment. The latter may cause patients to overtly complain to either the front desk personnel or the dentist employer. As such, if a dental hygienist is criticized for taking too much time updating medical histories during their review, they need to ask their employer, “What is the root cause of the concern or what are the consequences the updates are causing?”

In either case, a discussion is needed regarding the importance of medical histories in a dental practice. Dentist employers must realize that they and their personnel can be liable for adverse outcomes related to out-of-date medical histories when patients are treated in the dental office. According to the American Dental Association Council on Scientific Affairs, a completely new medical history on all patients of record should be obtained every 2 years.

If the patient has a complicated medical history, more frequent updating may be in order. Additionally, the medical history should be updated every time the patient is seen for clinical services by asking if there have been any changes since his/her last visit. These changes should be documented in the patient record; on the other hand, the fact that no changes were reported should also be noted.

While dentists are sued more often than dental hygienists, failure to keep the medical history of a patient up to date is a reason for litigation. Not updating or rushing through a medical history can lead to mistakes. Failure to prioritize medical history updates could put the patient and the practice at risk.

If in fact a dental hygienist is being penalized during a performance review for taking too much time on medical histories, a discussion should ensue regarding how to rectify the situation. If the dental hygienist is responsible for conducting the update, alternative approaches to updating histories should be considered. For instance, shorter medical history update forms can be created specifically for recare appointments. These can be completed by the patient online, printed, and brought to the dental appointment, allowing the dental hygienist to follow up on areas that need further review. Another method to expedite the process is to have the front desk staff provide the form so the patient can complete in the waiting room.

Implementing these procedures and emphasizing the importance of updating medical histories can save time for the dental hygienist, improve the overall patient flow for the entire office, and address any liability concerns.

 

The Ask the Expert column features answers to your most pressing clinical questions provided by Dimensions of Dental Hygiene’s online panel of key opinion leaders, including: Jacqueline J. Freudenthal, RDH, MHE, on anesthesia; Nancy K. Mann, RDH, MSEd, on cultural competency; Claudia Turcotte, CDA, RDH, MSDH, MSOSH, on ergonomics; Van B. Haywood, DMD, and Erin S. Boyleston, RDH, MS, on esthetic dentistry; Michele P. Carr, RDH, MA, EdD, on ethics and risk management; Denise Muesch Helm, RDH, EdD, on fluoride; Kandis V. Garland, RDH, MS, on infection control; Mary Kaye Scaramucci, RDH, MS, on instrument sharpen­ing; Kathleen O. Hodges, RDH, MS, on instrumentation; Karen Davis, RDH, BSDH, on insurance coding; Cynthia Stegeman, EdD, RDH, RD, LD, CDE, on nutrition; Olga A.C. Ibsen, RDH, MS, on oral pathology; Martha McComas, RDH, MS, on patient education; Michael W. Roberts, DDS, MScD, and Robert D. Elliott, DMD, MS, FAAPD, PA, on pediatric dentistry; Purnima Kumar DDS, PhD, on periodontal therapy; Ann Eshenaur Spolarich, RDH, PhD, on pharmacology; and Caren M. Barnes, RDH, MS, on polishing. Log on to dimensionsofdentalhygiene.com/asktheexpert to submit your question.

From Dimensions of Dental Hygiene. April 2023; 21(4):46.

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