Frequency of Medical History Updates
Health history questions should be asked at each recare appointment. The medical history is also a great time to educate patients on oral-systemic links, such as diabetes, heart disease, stroke, dementia, rheumatoid arthritis, and pregnancy complications.1 What patients deem insignificant may be very important when rendering treatment. As such, specific questions should be asked, rather than just checking if there are any changes to the medical history. For example, instead of asking “Are you still taking the same medications?” the clinician may ask “Are you still taking (list the names of each medication)?”
While legal action against dental hygienists is rare, one of the top reasons dental hygienists are sued is failure to update the medical history.2 As important as the medical history is, there are no legal requirements regarding the frequency for taking a complete medical history. It is a matter of clinical judgment with each patient. When determining the interval for a medical history update, the patient’s age, health, and history should be considered. Patients who have complicated medical histories need complete updating more often than healthy adults. The American Academy of Oral Medicine recommends that dental providers complete a comprehensive medical history at least once per year and more frequently on patients with complex medical histories.3 If a patient’s medical history is unclear or incomplete, a medical consultation may be required.3
Many electronic dental records contain medical histories that are easily updated by the clinician at each visit. At initial visits, most practices ask patients to fill out a medical history on paper. The American Dental Association (ADA) recommends that all new patients fill out a complete medical history, which should be reviewed at each subsequent visit.4 The ADA also notes that the form is only the first part of taking a medical history, and that interviewing the patient is necessary to obtain a complete history.4 The record should be updated, and the clinician should document the fact that the patient was asked about changes to his or her medical history and describe the changes. If the patient states there are no changes, this should also be documented.
- The American Academy for Oral Systemic Health. Oral Systemic Health Frequently Asked Questions. Available at: aaosh.org/resources/oral-systemicfaq. Accessed February 22, 2017.
- Glasscoe-Watterson D. Top reasons hygienists are sued. Available at: rdhmag.com/articles/print/volume-33/issue-11/features/top-reasons-hygienistsare- sued.html. Accessed February 22, 2017.
- American Academy of Oral Medicine. Medical History. Available at: aaom.com/index.php?option=com_content&view=article&id=108:medicalhistory& catid=24:clinical-practice-statement&Itemid=180. Accessed February 22, 2017.
- American Dental Association. Dental Records. Available at: ada.org/sections/ professionalResources/pdfs/dentalpractice_dental_records.pdf. Accessed February 22, 2017.