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A patient’s medical history provides vital information for planning and delivering safe and effective dental treatment. Managing patients who are living longer and have access to a wide variety of therapeutic agents can be a complex aspect of care.

The Ahpra Shared Code of Conduct describes general rules which imply that the medical history:

• forms part of the dental record and is confidential
• should be taken at the initial visit and documented
• should be regularly updated and these updates should be documented
• should be further investigated if there are concerns about the information collected.

The DBA encourages collaboration between healthcare practitioners to encourage safe and effective delivery of care.

Section 8.3 of the Code of Conduct makes statements which readily apply to medical history information. All information (including the medical history) must be:

• accurate, up-to-date, factual, objective and legible
• readily understood by other health practitioners
• held securely and not subject to unauthorised access (whether in electronic and/or in hard copy)
• respectful of patients and not include demeaning or derogatory remarks
• sufficient to facilitate continuity of care
• made at the time of events or as soon as possible afterwards
• made available when requested by patients.

 Considerations when deciding how to collect, use and store the medical history

• Although there is no requirement to obtain patients’ signatures, signed and dated medical history forms are considered ‘best practice’ and are particularly helpful if a dispute arises regarding medical complications.
• It is appropriate to record how and who reviewed the information collected, and when it was reviewed.
• Medical history alerts in patient records are helpful in managing risk.
• Reliable, consistent, and secure systems and procedures for the collection, review and use of the medical history help ensure information is not overlooked. Incomplete forms are not helpful to practitioners and usually imply that the history was never checked/ reviewed or updated.
• If scanning from paper to digital records, ensure scans are complete and legible.

Written patient completed questionnaire:

• Allow adequate time in your appointment system for the medical history form to be completed.
• The form should then be checked to ensure all necessary information has been recorded.
• Following with a verbal history helps to ensure that patients have remembered all details and understood the questions correctly.

Patient interview:

• A conversational approach can reveal forgotten or overlooked information that may have been missed with direct questioning. This approach can also help in establishing rapport.
• Provides the opportunity to identify and address gaps in the written questionnaire and ensures that it has been thoroughly reviewed.
• Taking time to ask relevant questions in response to the initial information provided can help to settle patients that are impatient, nervous or in pain.
• Provides an opportunity to explore patients’ social history which may provide added context and detail to the medical and dental history.
• Sometimes a patient might challenge the need for a detailed medical history assessment. A practitioner’s obligation is to ensure that they undertake the appropriate investigations to provide safe treatment. Should a complication arise, and it is established that there has been a failure by the practitioner to investigate thoroughly, a practitioner’s ability to justify proceeding with treatment will be impacted.

Contacting the patient’s doctor, specialist or pharmacist:

• This may be essential where the information provided is vague or the medical history is complex.
• A written statement of consent from the patient may be required when discussing patients’ medical history with other healthcare providers.

How often should a medical history be updated

The requirement is that practitioners are aware of the current medical history of their patients before providing treatment. As a patient’s medical history can change sometimes between appointments, it is essential that practitioners check their patients’ medical history at every appointment, and that the medical history findings and status be recorded (somewhere) in the patient file – this could be in the clinical notes or by completing a new patient filled medical questionnaire.

A patient filled questionnaire must always be checked by the practitioner for completeness and accuracy prior to treatment being provided.

Further information is also available in the ADA NSW   Dental Records Guide including the following helpful templates: