The Overlooked Basics
The Overlooked Basics
A summary of what every dental practice owner should know and implement in the day to day operations of their practice.
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Recording a Comprehensive Medical History

Recording a Comprehensive Medical History

4/25/2019 9:00:00 AM   |   Comments: 0   |   Views: 31
                                        
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.

OBERMAN LAW FIRM 

Stuart J. Oberman, Esq handles a wide range of legal issues for the dental profession including cyber security breaches, employment law, practice sales, OSHA, and HIPAA compliance, real estate transactions, lease agreements, noncompete agreements, dental board complaints, and professional corporations.
 
For questions or comments 
regarding this article 
please call (770) 554-1400
or visit 
www.obermanlaw.com
 
 Email Emily Scarborough at emily@obermanlaw.com to hear Stuart J. Oberman, Esq speak at your next event.

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