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:
• The patient’s current medications
• Medication changes
• Allergies to medications
• Recent physician visits or hospitalizations
• New physician care
• Medical changes since the last visit
• Current over-the-counter medications
• Any changes in the chart
If another staff member records a patient’s medical history, the dentist should always review the record orally with the patient and ask open-ended questions about the information provided.