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Patient Histories

Record-keepingIn addition to enabling patient identification and ensuring correct contact details,  collecting patient histories helps build up a picture of each patient’s previous dental experience, risk of developing oral disease, and informs assessment of their oral health status. It will also facilitate the provision of appropriate and safe dental treatment and the development of a care plan that is specific for each patient.

When a patient registers with the practice, record:

  • personal details (e.g. full name, date of birth, address, contact details, parent/carer/next of kin contact details (for child or vulnerable patients), name of general medical practitioner, CHI number, any special requirements)
  • social history (e.g. smoking habits, alcohol consumption, diet [e.g. eating habits, sugar and dietary acid intake], participation in contact sports, occupation)
  • dental history, including previous dental experience (e.g. oral hygiene habits, grinding of teeth, dental attendance, previous treatments e.g. orthodontic, implant, periodontal, acceptance of local anaesthetic, reason for attending)
  • medical history (e.g. existing medical conditions, current medication, allergies e.g. penecillin, family history of diabetes)
  • if the patient is anxious, or is suspected to be anxious. (NB: it is advisable to ask patients, when they first register with a dentist, whether they are anxious about any aspect of visiting the dentist.)

Example recording forms for the above are available (see under Templates).

Check that the patient understands all questions included in the forms and record the results of further investigations or discussions  (including telephone conversations) with the patient in the notes.

Include the date any form was completed, and ensure it is clear which practitioner recorded the patient’s details.

In the case of paper records, ensure the patient signs and the practitioner countersigns each form.

NB: From a legal point of view, if a computerised system is used, it would be considered best practice, particularly for the medical history form, for the patient and practitioner to sign a paper copy. This can be scanned and saved electronically. Patient completed records with electronic signatures e.g. CliniPads are acceptable as legally binding

At each recall appointment, check that all personal information (as listed above) for the patient is up to date, record and date any changes.

Record details of any cancelled or missed appointments.

Record any complaints made by the patient and any action taken by the practice (see Communication for more details on handling complaints). NB: Any correspondence relating to a complaint should be kept separately, as it is not directly related to patient clinical care.

Templates

The following example forms (pdf) for recording patient histories are also provided with SDCEP’s Oral Health Assessment and Review: