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Partnering with you to help create healthy smiles

QA tips: Get your patients’ medical history

Patients may grumble, but there’s a reason for the paperwork they fill out when they come in for a regular dental exam. Getting your patients’ most detailed, comprehensive history helps you deliver better results and prevents possible problems from occurring when providing dental care. Collect the right information upfront.

Get a complete health history 

Make sure your questionnaire contains simple yes/no questions that ask about the patient’s past and current health, including: 

  • General health and appearance 
  • Systemic and contagious diseases and conditions such as high blood pressure, diabetes, cancer and hepatitis
  • Recent dental problems, including toothaches, jaw issues, teeth grinding and bleeding
  • Use of dental appliances (nightguard, retainer, dentures)
  • Allergies and reactions to medications, anesthetics and materials (including latex)
  • Names and phone numbers of primary care physicians, specialists and emergency contacts 

Make sure the patient signs the health history with the date. 

Dentists sometimes see patients more regularly and more often than physicians. If this is the case, you can ask the patient to follow up with a physician if you suspect that the patient may have an underlying condition such as hypertension. 

If you have patients who may not understand this questionnaire in English, make your forms available in other languages. Remember, Delta Dental offers language assistance both over the phone and in person to help you communicate with your patients with limited English proficiency.

Prescription drug history

The use of some prescription drugs can trigger other problems for patients who receive dental treatment. For example, if a patient is taking bisphosphonates, the patient may have trouble building bone in the jaw, which can pose challenges for jaw surgery. 

And don’t just look at prescription drugs. Some supplements can be dangerous as well. Ginkgo biloba and vitamin E can be dangerous when taken with aspirin because they can thin the blood, causing complications if the patient is undergoing surgery. Make sure to also ask your patients about any vitamins or herbal supplements they may be taking.

Get medical history updates

A patient’s medical condition can change quickly. That’s why it’s important for each patient to provide an updated medical history at least once a year. Ask your patients to list any changes in their medical history each time they visit your office, and document any changes on their chart.

Take your time

Once a patient has filled out the questionnaire, review it carefully, noting any reasons for concern and following up with the patient for more information. Discussing your patients’ history may uncover additional issues that will help you better understand how their overall health affects their oral health. Remember to always document these conversations, especially if you uncover new information.

For instance, a patient might be reluctant to openly disclose an opioid addiction, but talking with him or her may bring out further information that indicates a struggle with drugs. 

Medical histories help you and the patient

Remember, it’s your responsibility to document your patients’ medical histories. It not only protects you from possible legal issues, but it also ensures that patients receive the best overall treatment possible.

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