Medical history update dilemma

Feb. 1, 2009
I know it's important to update our patients' medical histories. My concern is patients who hardly even look at the form and simply sign their names.

by Dianne Glasscoe-Watterson, RDH, BS
[email protected]

Dear Dianne,
I know it's important to update our patients' medical histories. My concern is patients who hardly even look at the form and simply sign their names. Also, filling out a new medical history is a source of frustration for some patients. Some scowl or grab the clipboard with a big sigh. Are there clear guidelines on how often patients should complete a new medical history? I've heard several different recommendations. The protocol in our practice is to have patients fill out a completely new form once a year. We ask them to fill out a shortened form every six months. Is this correct, or is it too much?
Thanks, Cathy J

Dear Cathy,

Your inquiry reminded me of a man I observed in a dental office. When the business assistant handed him a clipboard with a medical history and asked him for an update, he angrily jerked the clipboard from her and drew a diagonal line through the center. On the line he wrote in large letters, “NO CHANGES” and slammed it back down on the counter. The assistant and I were shocked at this man's rudeness. His behavior showed his obvious displeasure at being asked to fill out the form.

Why did he react this way to such a simple request? I don't think he enjoyed being rude. Rather, he saw the request as an imposition. He resented having to give this office the same information again and again. A weak analogy can be drawn by considering how you would feel if someone asked you the same question every time they saw you. Attendant to this is the hurried pace of so many people. They don't like to waste time, and to them, filling out forms is a waste of time.

Also, consider the growing problem of adult literacy in the United States. The results of the National Adult Literacy Survey in 2002 (conducted by the U.S. Department of Education) said that almost half of the U.S. population is either functionally illiterate or only marginally literate. According to the American Medical Association's publication, Health Literacy, a Manual for Clinicians, several studies reveal that those with limited literacy skills do not understand or are not aware of concepts basic to common diseases. Therefore, it is entirely possible that many of our patients are intimidated by the medical forms, which contain words they don't understand and can't read.

Please understand it's not your patient's responsibility to provide you with a complete medical history. Rather, it's your responsibility to obtain a complete medical history from your patient. This is why many medical practices now have a nurse sit down with the patient and go through the history, and the nurse writes down the documentation. The patient merely signs after the interview is completed.

The ADA recently obtained information from several of the major malpractice insurance carriers regarding record-keeping errors that played a part in various malpractice proceedings. The number one error noted was “no treatment plan,” and “health history is not clearly documented or not updated regularly” was number two. This highlights a shortcoming in many dental practices.

I asked the ADA Council on Scientific Affairs this question: How often should a patient be required to fill out a completely new medical history? They said that there is not a clear guideline, but medical histories should be updated at every patient visit. This does not mean you have the patient fill out a new form at each visit, but it does mean that the clinician inquires at each visit about possible changes in the medical status of the patient. Further, the clinician should document that the medical history was updated.

How often you ask patients to fill out a new form should depend on the patient. Common sense dictates that patients who have complicated medical histories need complete updating more often than average healthy adults. A three-year rule for new forms is not unreasonable. My advice is for you to sit with patients with medical complications and personally update the medical history form by asking the questions and recording the patient's answers. Patients should be asked to bring a list of their medications to be included as well. Also, personally update for any patient who displays even the slightest consternation at completing the forms.

Having patients fill out a new form once a year is not wrong, although the “paper blizzard” being created isn't necessary. My feeling is that anything we do that causes our patients unnecessary frustration does not promote good patient relationships and therefore should be modified.

There will be times when information provided by the patient about his or her medical conditions will require a telephone call to the patient's physician. Please make sure any consultations with a physician are recorded in the patient record.

According to Burton Pollack, DDS, MPH, JD, author of “Law and Risk Management in Dental Practice” (2002), there should be a few open-ended questions on the health history. “Health history forms on which the patient can only make check marks, circles, or underlines indicating yes or no answers can raise doubts as to who entered the responses if the health history is reviewed in a judicial proceeding. Your history forms should be designed so that patients write their responses to open-ended questions,” he wrote.

In consulting with various attorneys, it is my understanding that signatures never expire. Please have patients sign any new forms they complete. However, updates to those forms do not require another signature. Of course, the clinician should sign the updated entries in the interim.

Patients have many reasons for balking at our forms. Whatever they are, we can make this a nonissue by assisting them through the maze of questions and medical terms. We take the pressure off patients by showing a personal interest in their health and giving our attention to this very important part of comprehensive patient care. It is part of “walking the walk and talking the talk” that oral health is connected to overall physical health.
Best wishes, Dianne