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 toward 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 every 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.
Stuart J. Oberman, Esq.
Stuart J. Oberman is the founder and President of Oberman Law Firm. Mr. Oberman graduated from Urbana University and received his law degree from John Marshall Law School. Mr. Oberman has been practicing law for over 30 years, and before going into private practice, Mr. Oberman was in-house counsel for a Fortune 500 Company.
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