Medical History: An Office's Responsibility

Feb. 25, 2008
One of the most important aspects of a patient record is an updateable medical history.

by Carol Tekavec, CDA, RDH

Electronic dental records, computerized systems, and paper charts must all include certain key elements to make them thorough, accurate, and defensible. One of the most important aspects of a patient record is an updateable medical history. Here we strive for simplicity and accuracy. It is also imperative that a chart as a whole lends itself to organized, accurate, and appropriate patient treatment. As one physician said, "Doctors want to take care of patients. They don't want to become specialists in creating medical records."

With this in mind, the patient's chart does not just prevent malpractice; it is a blueprint for care and treatment. When it is correct it makes life easier for everyone involved.

Let's examine the patient medical history. What should it include? How often should it be updated? Who should complete it? When should it be completed? How is HIPAA (Health Insurance Portability and Accountability Act) implicated?

What should a patient's medical history include?
New information about what types of systemic conditions can impact dental health and vice versa comes out almost daily. Medical history formats that are even six months old can be out of date. Personalized entries are important. Computer systems that do not allow for individual remarks and explanations limit the types of conditions that can be noted. Prewritten templates or cut-and-paste functions are usually not patient specific. Therefore, a medical history should not be "macroed." Current thinking on a medical history format indicates:

• It should include systemic diseases, allergies, reactions to anesthetics, current medications and treatment, herbal supplements, surgeries, injuries, and diet.
• It should list the patient's physician and phone number, and be signed and dated by both the patient and dentist. Computerized systems should accommodate this requirement, whether it be with a "writeable" screen or some other type of mechanism.
• It should have a section to list follow-up remarks from the dentist.
• Updates at appropriate intervals are necessary. All updates should be signed and dated by both the patient and dentist. An update can be part of a medical history form, or simply noted in the progress notes. It should reflect any changes or that there are no changes.
• The format should be proactive. In other words, the patient should be able to indicate with yes or no what conditions apply to him/her. This ensures that a patient does not overlook a condition by mistake.
• A format to allow for a medical alert notation, label, sticker, or other way of attracting attention should be included so that important health considerations are not overlooked.

How often should a medical history be updated?
• An update should be accomplished at least once a year, or whenever the patient has a major change in health.

Who should complete the medical history?
• All patients of the office must have a documented medical history. Adult patients may complete their own histories, and minor children must have a parent or guardian complete their history. History forms may be mailed to patients in advance for them to bring to their appointment, computer literate patients may download forms from the Internet, or patients may simply complete forms at the office.
• Regardless of the method, patients frequently require help completing these histories. It is typically the dental assistant's task to make sure that all sections of the history have been addressed. Conditions that should be brought to the dentist's attention can be highlighted in yellow on a paper form, or otherwise computer-identified.

When should the history be completed?
• Patients may complete the history at home or in the office prior to their appointment. Emergency patients must also complete a thorough history before treatment. Recall patients should have an update at least once a year, or whenever a major change occurs in their general health.

How is HIPAA (Health Insurance Portability and Accountability Act) implicated?
• Misconceptions continue to circulate about the HIPAA privacy rule. Information specifically addressing privacy issues for dentists can be found in the ADA HIPAA Privacy Kit, which sells for about $125 and may be ordered directly from the ADA.

The following excerpts are taken from the HIPAA Web site:
• According to 45CFR 164.530c of the privacy rule, a health-care provider must have in place appropriate physical safeguards to protect patients against uses and disclosures not permitted by the privacy rule. The physical storage of records must be protected from exposure to individuals who are not listed in the office's "Notice of Privacy Practices." This notice details in writing all specific protections put in place by the practice.
• According to the same section of the privacy rule; Health and Human Services did not intend for the privacy rule to impede necessary practices or change common patient records. The rule states that covered entities such as dental offices may tailor their privacy measures to their particular circumstances and utilize reasonable safeguards. Whether information is contained within a paper record or on the outside of the record, access to the chart must be limited to those considered appropriate by the health-care provider. Reasonable care should be taken on some types of information. For example, instead of writing "allergy to penicillin" on the outside of a record, a label should be placed that indicates providers need to check the patient's medical history prior to treatment. Patient safety is as important as privacy.
• Digitized formats require computer security with passwords or "biometric" fingerprint identification for access to record systems. Personal or automatic log off and lock out features that prevent changes in entries after a specified time are also essential.
• Six HIPAA Basics
1. A dental office needs to have a written privacy policy
2. A dental office needs to provide a copy of the privacy policy to all staff and document that it has been distributed.
3. A dental office needs to select a privacy officer who will make many of the decisions involved in implementing the office's privacy policy. The same person may be designated a contact officer to receive complaints.
4. A dental office needs to establish procedures for disciplining staff members who violate the office's privacy policy.
5. A dental office needs to provide all patients with a "Notice of Privacy Practices" specific to the practice.
6. A dental office needs to make a good faith effort to obtain a signature on an "Acknowledgement of Receipt of Notice of Privacy Practices."

Detailed record keeping and an updateable medical history are important to every dental practice, regardless of whether the office is using paper or computerized charts. It is imperative that a chart or digitized record be organized, accurate, and appropriate.

Carol Tekavec, CDA, RDH, is the president of Stepping Stones to Success and a practicing clinical hygienist. She is a consultant to the ADA Council on Dental Practice and a presenter for the ADA Seminar Series. She has appeared at all major U.S. dental meetings and is the designer of a patient charting system,The First Encounter. She is the author of the Dental Insurance Coding Handbook 2005-2008, as well as five patient brochures. She was the insurance columnist to Dental Economics® magazine from 1995-2006. Contact her through her Web site at, or (800) 548-2164.