If your patient had a medical emergency and your team had to call 911, how long would it take you to pull up his or her most current medical history? Is the list of current medications and allergies buried among all your clinical notes or does your most recently scanned health history form have the words “no changes” all over it, forcing you to continue searching back to the next scanned document … only to find the words “no changes” all over this one as well. It’s not just about being prepared for an emergency … it’s about being prepared for anything.During the time I was working in my practice full time, my doctor performed complicated surgical procedures and placed dental implants on a regular basis. We had a patient whose dental implant did not integrate and she had several complications during the healing time and, in the end, we ended up removing the implant because it was just not in the cards for her. She decided that it had been the doctor’s fault that her implant failed and I remember working with our malpractice insurance company trying to piece together all her documentation into a timeline beginning with her first visit.
In my opinion, the health history should have at minimum six pieces of critical information. If you are a more detailed clinician, there are other pieces you can add as well. Here are my top six pieces and a few alternates . . .
- Current medical conditions, recent surgeries and hospital visits. This should never say “no changes.” You should always have a list of what is current at this point in time. If they are diabetic last visit, they are more than likely diabetic now. List it. Don’t write “no changes.”
- Current prescription medications, over the counter medications and herbal supplements. If their medication list didn’t change from last time, never write “no changes.” You should have a date stamp with their current medication list every time.
- Current allergies, including reactions to local anesthetics. Again, if they are allergic to latex, then your health history update today should list Latex Allergy not “no changes.”
- Today’s BP and pulse. I had a doctor recently say to me, “I am not their medical doctor and my patients say they will leave my practice if I force them to take blood pressure.” Okay there are two parts to this comment. First, you are their oral health physician so start acting like it. Second, if your patient is going to leave you because you care, let him or her go.
- Emergency contact name, relationship and mobile number
- Physician name and contact info
- Tobacco use
- Pregnancy (this could go in #1 even though it is a temporary condition)
I love using the Questionnaire module in Dentrix because it is efficient for your clinical team. There is no scanning and you can use an iPad or tablet if you do not have a monitor in the treatment room that the patient can see. The Dentrix Questionnaire module will turn any paper form into an electronic form and the way it auto-fills information from previous appointments makes it about a 30-second task for the clinician. These electronic forms can be digitally signed and locked up into history for added security.
If you would like a sample Health History Update that I use in many offices in the Questionnaire module, email me directly at dayna@raedentalmanagement.com.
If you would like a sample Health History Update that I use in many offices in the Questionnaire module, email me directly at dayna@raedentalmanagement.com.
I created a video on how to create an electronic form in the Questionnaire module and you can watch it by CLICKING HERE.