One of the first principles we learn at dental school is the importance of taking a detailed medical history before treating any patient. Most dental schools have their own designed medical history questionnaire, and this shapes the format, style, and extent of any further questioning of the patient on points arising from their medical history.

Many practices, in similar fashion, use their own medical history questionnaires that patients are asked to complete when attending the practice for the first time. In most cases the design provides for the patient to answer “yes” or “no” to a set of predetermined questions, and then to sign and date the completed questionnaire. The dental healthcare professional (DHP) then ensures that the patient has properly understood all the questions (for example, where patients leave one or more answers blank), and where “yes” answers have been given, further questioning of the patient will allow the details of any response to be clarified and expanded upon. Sometimes this highlights areas where further information needs to be gathered – perhaps contacting the patient’s medical practitioner, with the patient’s consent, or by asking the patient to bring a list of any medication they are taking along to their visit, so that the precise drugs and dosages can be identified with certainty.

When things go wrong

In several recent cases, the patient’s medical history has been at the heart of negligence claims brought against dentists and other dental team members. For example, a failure to consider certain allergies to drugs, especially penicillin and other antibiotics, or to recognise the significance of long-term anticoagulants predisposing to postoperative bleeding, or the potential for drug interactions. Medications can also have side effects that cause visible changes in the soft tissue, for example phenytoin, calcium channel blockers and anti-retroviral preparations.

Cases such as these often reveal that although a clinician might have taken a comprehensive medical history when the patient first attended as a new patient, this process has either not been repeated or has been much more superficial, when the patient has returned for successive courses of treatment. In most cases, no further written medical history questionnaire is ever undertaken, and indeed there is rarely any note on the record card to confirm what (if any) further questioning has taken place to update the patient's medical history.

This can be a considerable embarrassment when the patient has attended the same practice over many years, and the clinician is apparently still relying on the patient's original medical history details.

Medical histories change

It is self-evident that a patient’s medical history status is not static and indeed a patient's medication prescribed by others may change from visit to visit. It is prudent, therefore, to ensure not only those changes in medical history, including medication, are regularly checked and updated, but also that this fact is clearly recorded as a dated entry in the patient’s clinical notes. The Code of Practice: Professional Behaviour and Ethical Conduct states:


“9.1  You must keep legible, accurate, comprehensive and up-to-date records for all your patients”, and this would include their medical history.”

Many DHPs take medical health histories verbally and if no positive or significant responses are elicited, an entry such as “MH – nil” is made in the records. While better than no entry, this approach carries the disadvantage that it can be difficult or impossible to establish precisely what questions were asked of the patient, in what terms, and what answers were given.

A well-structured health record questionnaire form, which is completed, signed, and dated by the patient, and subsequently updated on a regular basis, ideally, during each successive course of treatment, is not only in the patient’s best interest, but is also the best platform for the successful defence of cases where failure to elicit or act upon a relevant aspect of medical history leads to avoidable harm to the patient. If there is doubt regarding a patient’s medical history, it may be sensible to defer treatment pending clarification of any areas of uncertainty. In all cases, the taking and confirmation of a medical history is the role of the DHP and is certainly a key part of a DHP’s duty of care.