Re-printed from The Progressive Dentist November issue by Dayna Johnson
If your patient had a medical emergency and your team had to call 911, how long would it take you to pull up his or her most current medical history? Is the list of current medications and allergies buried among all your clinical notes or does your most recently scanned health history form have the word “no changes” all over it, forcing you to continue searching back to the next scanned document only to find the words “no changes” all over this one as well. Get a stopwatch out and time yourself. How long would it take you and your team to piece together a current snapshot of your patient’s medical conditions, medications and allergies if you needed to call 911? I realize it is very uncommon to experience a medical emergency in the dental practice. However, if I was your patient, I would want you to be as prepared as possible.
When I was working in the dental practice, we would do emergency scenario practice once a year, making sure our emergency plan worksheet was updated and our emergency kit had supplies that were not expired … but how many of you do a dry run with your health history update? I work with hundreds of offices a year and I have not seen one practice yet that would be prepared. That is sad. You are putting your patient’s health at risk by not having a simple, convenient and efficient way to pull up a snapshot of your patient’s health.
It’s not just about being prepared for an emergency. It’s about being prepared for anything. During the time I was working in my practice full time, my doctor performed complicated surgical procedures and placed dental implants on a regular basis. We all know that the human body is a complex, biological system and everything from medications to the environment can affect the success of a dental implant. We had a patient whose dental implant did not integrate and she had several complications during the healing time. In the end, we ended up removing the implant because it was just not in the cards for her. She decided that it had been the doctor’s fault that her implant failed and I remember working with our malpractice insurance company trying to piece together all her documentation into a timeline beginning with her first visit.
If this happened to you, would you be able to easily pull up a snapshot of her health? Would you be able to see at any point in time she came in what her medical conditions were, what medications she was taking and if she had any allergies? Would you be able to see quickly when she started one medication and stopped another? Can you easily compare a patient’s health from one date to another? If you answer no to any of these questions, it is time to re-design your health history update.
The health history update is usually the one piece of information that the practice does not know how to deal with when they are transitioning to a paperless environment so they end up keeping the status quo and continue pulling the charts. This is a great time to re-evaluate how you are documenting your patient’s health history. I can guarantee your practice management software has a better way to do it than on paper. What happens with paper is that no one wants to fill out a new form so the practice just writes “no changes” on a new form or prints out the old one and writes in the new medication with a date and re-scans it … or they don’t do it at all and just ask the patient verbally and write it in the clinical note. Sound familiar? I thought so.
How often should you be updating the health history and who is responsible? This is when I hear answers all over the board. “Aren’t we required to do it once a year by law?” or “The hygienists do it at the recare visit” or “Isn’t the front office supposed to be doing it with every patient?” The answer is, “You should be documenting a health history update every time you hear that something has changed and it is NOT a front office task.” I agree with you that the health history update is typically updated at the hygiene visit. However, with the recare visit being so crunched for time, it is common to cut corners and I know the clinician is not going to cut corners with treating the patient … she is going to cut corners with a form instead. Let me put it to you this way . . . the patient is not going to die if you miss some of the calculus, but you are compromising his or her health if you miss some details on the health history. That might sound harsh but it’s the truth.
Okay, we have talked about why the health history update is so extremely important. Now let’s fill in what should go on the form and ideas on how to make it more efficient for your team.
In my opinion, the health history should have at minimum six pieces of critical information. If you are a more detailed clinician, then there are other pieces you can add as well. Here are my top six pieces and a few alternates . . .
- Current medical conditions, recent surgeries and hospital visits. This should never say “no changes.” You should always have a list of what is current at this point in time. If they are diabetic last visit, they are more than likely diabetic now so list it don’t write “no changes.”
- Current prescription medications, over the counter medications and herbal supplements. If their medication list didn’t change from last time, never write “no changes.” You should have a date stamp with their current medication list every time.
- Current allergies, including reactions to local anesthetics. Again, if they are allergic to latex, then your health history update today should list Latex Allergy not “no changes.”
- Today’s BP and pulse. I had a doctor recently say to me, “I am not their medical doctor and my patients say they will leave my practice if I force them to take blood pressure.” Okay there are two parts to this comment. First, you are their oral health physician so start acting like it. Second, if your patient is going to leave you because you care, then let him or her go.
- Emergency contact name, relationship and mobile number
- Physician name and contact info
- Tobacco use
- Pregnancy (this could go in #1 even though it is a temporary medical condition)
There are many ways you can make this happen. The first thing I would do is see how your practice management software can solve the health history issue. Many of you know that I am a certified Dentrix trainer and, since it is the leading practice management software in the country, I will use it as an example.
I love using the Questionnaire module in Dentrix because it is efficient for your clinical team. There is no scanning and you can use an iPad or tablet if you do not have a monitor in the treatment room that the patient can see. The Dentrix Questionnaire module will turn any paper form into an electronic form. The way it auto-fills information from previous appointments makes it about a 30-second task for the clinician. These electronic forms can be digitally signed and locked up into history for added security.
As you can see, I am very passionate about your clinical documentation. I am helping you protect your patient and your license. If you would like a sample of the health history update I use with my clients, please email me directly and I would be more than happy to send it to you.