Medical/dental health history

Your practice should have a complete and accurate medical and dental health history for each new or active patient of record before any diagnosis or treatment takes place. Some of the steps in that process include:. This process sets the tone for a positive patient experience for both new patients and active dental patients of record.

They may also not want to disclose that that they are taking suboxone or some other legal alternative, such as methadone.

The dental history should include

Failure to obtain a complete history from a new patient, or an updated history from a current patient, could put the patient, and the practice, at risk. You may want to consider whether to accept patients who either refuse to complete health history forms or who intentionally do not provide honest, accurate and complete information.

The document is available in both English and Spanish; different forms are available for children and adults. All patients of record should be asked to complete a new health history form every two years. Be sure to document efforts to recall the patient and whether or not they have been successful. That notation should include the date of the discussion and indicate which staff member s initiated the conversation.

The record should then be updated to reflect the new information. This type of scenario has the potential to put you and the practice at significant risk: imagine what you would do in a situation involving a hypertensive patient without a current physician. Appropriate actions in that situation could include:. Both the dentist and patient should sign or e-sign the form once the review and conversation are over.

Each of these categories of active patients of record can be further divided into: 1 new or regular patients who have had a complete examination done by the dentist and, 2 emergency patients who have only had a limited examination done by the dentist. Advising the patient that dental treatment must be delayed until the condition is managed by a physician; this is especially important before treating patients with hypertension or uncontrolled diabetes.

Possibly following up with the patient via a phone call or a letter to request confirmation that they have seen a physician.