Medical/Dental Health History

Guidelines for Practice Success | Managing Professional Risks | Patient Records, Charting, and Documentation Protocols

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.

While the dentist may designate a staff member to assist in the process of having patients complete and/or update their medical/dental health history forms, remember that you, as the dentist, are fully responsible for obtaining, maintaining and reviewing patients’ up-to-date health histories.

Maintaining patients’ current health histories is more than simply filing the information: like other aspects of managing the practice, this is a multi-step process. Some of the steps in that process include:

  • Making sure that patients understand the questions
  • Encouraging patients to ask questions of the dentist or staff if they do not understand the form or any of the questions it contain
  • Ensuring that all questions are answered fully
  • Obtaining the patient’s signature on the completed form

The health history form is the starting point for the practice’s relationship with the patient. It’s valuable because it provides appropriate staff members with information that they need in order to fulfill their professional obligations.

Keep in mind that the patient’s interaction with the staff and the dentist during the health history collection process is at least as important as the information detailed on the form itself. This process sets the tone for a positive patient experience for both new patients and active dental patients of record.

An accurate medical/dental health history is vital since it may provide valuable information for the dentist prior to beginning treatment, especially since certain medications can influence treatment decisions or may impact post-operative care instructions. It’s also important to recognize that patients who are current or recovered opioid users may be reluctant to reveal that aspect of their medical history. They may also not want to disclose that that they are taking suboxone or some other legal alternative, such as methadone. 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.

A patient’s health history form must be complete and should be reviewed with documentation in the patient’s record. 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.

Some of the issues that can be covered in a health history form include:

  • The patient’s health conditions and illnesses
  • Contact information for the patient’s primary health care provider and/or any specialists coordinating specific medical treatment
  • Current medications that the patient is taking
    • This information is important because:
      • certain drugs can interact with local anesthetics or other drugs the dentist may prescribe
      • some medications may affect dental treatment or the patient's other health condition(s)
      • certain drugs may impact post-operative care instructions
  • The reason(s) the patient is seeking dental care
  • Space to record additional information acquired during the dentist’s conversation with the patient.

Sample health history forms are available through the American Dental Association’s (ADA) Department of Product Development and Sales and can be ordered online. The document is available in both English and Spanish; different forms are available for children and adults.

Once the medical/dental health history form is completed, the dentist should:

  • Carefully review the health history form before greeting the patient
  • Discuss the contents of the form with the patient before initiating any examination, diagnosis or treatment
    • This conversation is an important element of the health history process
    • The dentist should record any new details or additional information on the health history form
  • Be prepared to answer any questions the patient may have regarding the form
    • Since it’s impossible for a single form to address every possible aspect of an individual’s health history, you may need to ask follow-up questions that focus on issues related to that specific patient’s specific health concerns.
  • Both the dentist and patient should sign or e-sign the form once the review and conversation are over.

While new patients will complete the medical/dental health history form immediately before the first appointment, practices are encouraged to ask active dental patients of record to review, confirm and update their medical/dental health history records, including the list of current medications, at every appointment. All patients of record should be asked to complete a new health history form every two years. This process can greatly reduce the possibility that the patient will inadvertently neglect to advise the dentist and staff of recent changes to his/her health status. You may also want to consult your professional liability insurance company and a qualified attorney to ensure you’re in compliance with the recommended best practices for your location.

It is important to note that a patient may not be an “active patient” but is are still a patient of record unless the doctor-patient relationship has been terminated by the dentist or the patient. Be sure to document efforts to recall the patient and whether or not they have been successful. There could be risks associated with a “non-active” patient, especially if office policies and patient non-compliance are not well-documented.

If you’re uncertain regarding which patients should be considered “active dental patients of record,” ADA policy defines the term as:

“An active dental patient of record is any individual in either of the following two categories: Category I—patients of record who have had dental service(s) provided by the dentist in the past twelve (12) months; Category II—patients of record who have had dental service(s) provided by the dentist in the past twenty-four (24) months, but not within the past twelve (12) months. Patients who have requested their records be transferred to another dentist or who have indicated they will be discontinuing their treatment, as substantiated in the patient’s record, should be excluded from the “active” patient category. 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.”
Excerpted from Active and Inactive Dental Patients of Record (Trans.1991:621; 2012:441)

Be sure to make a notation in the patient’s record that indicates the patient was asked about recent health and medication changes. 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.

It’s possible that, at some time in your career, you may encounter a patient who reports no known significant medical issues or one who reports not having a current physician. 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:

  • Documenting physical findings, such as the patient’s blood pressure and pulse.
  • Documenting the patient’s condition in the record and notating that you encouraged the patient to see a physician.
  • 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.
  • Recognizing that you may opt to dismiss the patient from the practice if he/she fails to see a physician in order to have the medical condition consulted or treated.
    • While dismissing a patient is never an easy decision to make, there are times when it is the best decision.
    • Dentists are not obligated to accept and treat every patient who comes into the practice.