THE IMPORTANCE OF RECORDING

THE MEDICAL HISTORY

Every practising dentist has a responsibility to maintain good quality clinical records. This has been clearly stated by the GDC and also reinforced by bodies such as the BDA and GDPA. Clinical records are fundamental to the process of the delivery of dental care, contributing to the diagnosis, planning and correct sequencing of treatment. Moreover, accurate records are essential to ensuring that patients receive appropriate and safe treatment. A comprehensive, up-to-date medical history comprises one of several components of good clinical records.

The systematic taking of a general medical history by dentists is important for several reasons, all of which are closely related to the quality of care provided to patients:

• It enables dentists to obtain information necessary to provide appropriate, individualised care. A medical history helps to identify conditions relevant to the patient’s dental health or which could have an impact on how treatment is carried out, e.g. conditions which require antibiotic prophylaxis or preclude certain treatment or prescription of certain drugs (drug allergies and interactions).

• Information about certain medical conditions such as diabetes, epilepsy, allergies or heart disease could be vital if a medical emergency occurs in the dental practice

• Recording a medical history is an important adjunct to the opportunistic monitoring of the oral soft tissues, enable the dentist to identify and address risk factors for oral cancer.

• Medical histories reveal critical information required to address infection control issues. Despite the fact that cross infection control in dentistry is generally based on the principle of “universal precautions”, in certain cases it is necessary to try and identify members of “at risk” groups such as those “at risk” of developing iatrogenic Creutzfeldt-Jakob Disease (CJD).

• To prevent medical complications and thus minimise detrimental effects to the patient and the possibility of medico-legal complications for the dentist.

In summary, the recording of an accurate medical history is in the best interest of patients and dental staff alike.

Aims and Objectives

• To determine whether an accurate, comprehensive and up-to-date medical history is currently recorded for each dental patient by comparing existing practice to a set standard

• To identify areas of weakness in accurately recording the medical history
• To implement changes to improve the quality and standard of recording medical histories and to determine whether these have been effective

The Set Standard

The standard for this clinical audit is defined as follows:

95% of all patients’ records should satisfy ALL the following FIVE criteria

1. A medical history form should be present in the record card

2. A medical history form should be signed and dated (the day of completion) by the patient / parent /guardian

3. The medical history form should be updated at the last recall appointment

4. Every question on the medical history form should be answered (yes/no), including those dealing with personal details and doctor’s information

5. All details of the medication (if appropriate) including the name(s) and dosage(s) of drugs taken should be recorded

Methods and Materials

Selection of Subjects

A total of 150 patient record cards consisting of 50 from each of the three dentists working at the practice were selected by systematic random means. This involved taking the first 50 record cards from each dentist’s schedule file. No specific inclusion or exclusion criteria were applied, i.e. all 150 record cards selected were included in the present study.

Data Collection

A pro forma was designed to collect information from each of the 150 patient record cards (figure 1) and was completed by simply placing a tick in the relevant “yes” or “no” box next to each of the five criteria defined by the set standard.

Figure 1

CRITERIA	YES	NO
MH form in card
MH form signed and dated
MH form updated at last recall appointment
Every question answered on MH form
All details of medication recorded

Re-Evaluation of the Set Standard

After the first audit cycle, the set standard was modified and defined as follows:

95% of all patients’ records should satisfy ALL the following FIVE criteria

1. A medical history form should be present in the record card

2. A medical history form should be signed and dated (the day of completion) by the patient / parent /guardian

3. The medical history form should be updated at the last recall appointment

4. Every question on the medical history form should be answered (yes/no), including those dealing with personal details and doctor’s information

5. All details of the medication (if appropriate) including the name(s) of the drugs taken should be recorded

N.B. Only Criterion 5 has been modified – the “dosage(s)” of the drugs taken has been omitted

Graph

Conclusions

• The medical history remains an important element in clinical record keeping. The questionnaire, in addition to the patient interview and clinical examination, contributes to the proper evaluation of the patient and facilitates overall dental care.

• There is little information in the literature concerning the standard of medical history recording thought to be adequate and the questions necessary for comprehensive medical history taking. It is therefore suggested that efforts need to be made by the dental profession to set standards and formulate guidelines to establish a more standardised medical history questionnaire.

• The clinical audit undertaken showed that the current standard of recording the medical history was inadequate

• Although the target standard of 95% was not met after the implementation change, it produced an improvement in standards from 45.3% to 89.3%. This emphasises the value of clinical audit in general dental practice.

Appendix

A table to show the standard achieved for each criterion in Cycles 1 and 2

of the Clinical Audit

STANDARD CRITERIA	NUMBER (n) / PERCENTAGE (%) OF PATIENTS
	AUDIT CYCLE 1		AUDIT CYCLE 2
	n	%	n	%
MH form present in card	149	99.3	150	100.0
MH form signed and dated	149	99.3	148	98.7
MH form updated at last recall appointment	88	58.7	150	100.0
Every question on MH form answered	138	92.0	137	91.3
All details of medication recorded	110	73.3	147	98.0

A table to show the standard achieved overall in Cycles 1 & 2 of the Clinical Audit compared to the set standard (95%)

	STANDARD ACHIEVED (n – number of patients, % = percentage of patients)
	n	%
AUDIT CYCLE 1	68	45.3
AUDIT CYCLE 2	134	89.3
SET STANDARD	142.5	95.0