Recording a Comprehensive Medical History

Before any procedure, a dentist should always review the patient’s file and medical history. The medical history allows the dentist to move in a safe direction towards treatment. A patient’s medical history holds great importance in the informed consent process as the dentist explains how medical conditions may impact a patient’s safety. In addition, knowing a patient’s medical history allows the dentist to prevent adverse unexpected results.

A patient’s medical history should be updated every visit. Updates to the medical history records ever visit should include:
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Ensuring the Patient’s Consent is Valid

Informed consent grants patients the ability to make thoughtful and informed decisions regarding their dental treatment.This process includes providing information regarding the purpose, procedure, potential risks and benefits, as well as alternative options. 

Having an informed consent process in place ultimately enhances a patient’s understanding and guides their expectations while potentially decreasing the liability of the dentist. In order to ensure the validity of the patient’s consent, the dentist should:
• Have a comprehensive understanding of the patient’s medical history.
• Have the same dentist administering informed consent and performing the procedure.
• Inform the patient of his/ her qualifications, experience, and training to perform the procedure.
• Disclose information regarding the nature and purpose of the procedure, probable risks and benefits, unusual and serious risks (such as death), and the consequences of refusing treatment.
• Give the patient the opportunity to think about the information and ask questions.
• Ensure that the patient is legally and mentally able to give informed consent.
• Never coerce the patient to provide informed consent.
• Provide the patient with a specialist’s information as a treatment option.
• Never go beyond the scope of the outline procedure while the patient is under sedation. The dentist should only complete the agreed upon procedures.
• Heavily document or refuse cases in which the patient chooses to waive his or her right to informed consent. 
For every dental procedure, the dentist should:
1. Have an informed consent form that all patients should sign before performing a procedure.
2. Keep a detailed record of the patient’s history.
3. Maintain a thorough record of the treatment plan and financial services in the patient’s file.
4. Take clear and detailed notes, and include the notes in the patient’s file.