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. |