When should a medical history form be updated? The answer is: it varies. That's probably not the hard and fast rule you hoped for, but the good news is that there are a few rules of thumb and things you can keep in the back of your mind that will help you know when to update your patients' medical history forms.
The Importance of Updating Medical History Forms
Up-to-date medical history forms are vital for your dental practice's safety and for your patient's health.
If you are not confident that your records are up to date, the answer to the question, "When should a medical history form be updated?" is: Right now.
Patients can request their medical history from your practice at any time. Without up-to-date medical history forms, dangerous gaps in knowledge, such as incomplete drug histories or unreported preexisting medical conditions, can complicate dental care, jeopardize patients' oral health, and increase your risk of liability.
No matter how you do it, the most important thing to do is gather up-to-date medical history forms.
What Kind of Records Should I Keep for My Dental Practice?
Every time a patient comes in for an appointment, whether for a cleaning or oral surgery, you should review their medical history form to ensure it's complete. The specific information relating to your type of practice or facility will dictate some of what you record, but there are common items that belong on every medical history form. Here are some things you should include on your medical history forms:
- The patient's health conditions and illnesses
- Contact information for the patient's primary care doctor and any specialists they are seeing
- The reason the patient is seeking dental care
- Space to write in any new information the patient volunteers during his or her visit.
Gathering this information can help you craft better courses of treatment, improve your patients' experiences, and insulate you from legal risks related to malpractice.
Gathering and Storing Medical History Forms
So, when should a medical history form be updated?
As a rule of thumb, best practice dictates that medical history forms in dentistry should be updated at least once per year. You should also update them any time there is a change in the patient's health status or a new drug is introduced to their current medication regimen.
If you want to be extra safe, you can have every patient update their medical history form at each visit or you can walk back the frequency from there if you so choose. The patient's age and health status determine the urgency to keep their medical records up to date. Generally, updating medical history forms once a year is sufficient if a patient is in good health.
If you're looking for maximum ease of use, accuracy, and frequency, you can have your patients update their medical history via an online patient portal like the Dental Intelligence Patient Portal. This takes the hassle of filing, administering, and refiling medical history forms off your plate permanently. With a digital patient portal, every record is just a click away.
Once you've got the right information in your hands, you have to decide how your practice will process it at volume. The old method of using paper and a forest of filing cabinets in your backroom introduces unnecessary risk. Theft, unauthorized access, natural disaster, fire, and other catastrophic events can destroy or compromise your records in a heartbeat, leaving you with the headache of cleaning up the mess.
Digitizing your records reduces that risk significantly and saves floor space in your practice. Putting your records in the care of a trustworthy, decentralized third party that follows HIPAA practices for patient data storage gives you an added measure of security against the worst-case scenario.
The Bottom Line
For dental practices, keeping up-to-date medical history records for their patients is a crucial discipline with a lot of weight riding on it.
When should a medical history form be updated? The only way to prevent the pitfalls that come from poor medical history form management is to review and follow dental documentation guidelines. Getting the right information from patients in a timely manner and filing it in a secure, easy-to-access location is the best way to make sure your protocols are setting you up for success.
If you want to know more about how Dental Intelligence can help you make medical history form management a breeze, contact us today to schedule a demo to see features like our Digital Forms and more.