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Medical Histories for the Computerized Practice

From Volume 45, Issue 1, January 2018 | Pages 57-62

Authors

Richard Lilleker

BDS

Gwynne Dental, 41 Cliddesden Road, Basingstoke RG21 3EP, UK (richard@gwynnedental.co.uk)

Articles by Richard Lilleker

Abstract

Taking a comprehensive medical history is a prerequisite for treating every patient. This paper will explore the current requirements and suggest how computerized practices might efficiently achieve them. It is suggested that practices consider their patient journey and information flow and a medical history form is presented which should facilitate the process. Audit and monitoring provide a means for continual improvements.

CPD/Clinical Relevance: Improving the process of taking and recording medical histories will save clinical time and improve patient safety.

Article

Taking a comprehensive medical history (MH) is a prerequisite for treating every patient, yet many medical history forms (MHF) and the processes used in practices may be outdated. In a busy dental practice it can be challenging to find the time to discuss and record a MH thoroughly, but obviously any errors or omissions could have potentially serious consequences,1,2 The relevance of particular medical conditions to dentistry are covered in detail in a recent paper and therefore will not be discussed further here.3 Confidentiality is an absolute requirement throughout the MH process but is outside the scope of this paper; obviously indiscreet discussion of medical details should be avoided. This paper will focus on the current requirements and consider the process and practicalities of taking a MH in a busy computerized practice.

The GDC states that ‘You must make and keep complete and accurate patient records, including an up-to-date medical history, each time that you treat patients’.4

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