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The Who, What, When, Where, and How of Health Histories

Posted on Jun 18, 2019 by Roy Shelburne

    Understanding the importance of health historiesIt seems that patient health histories continue to be a thorn in the flesh for many dental practices.  There are way too often, misconceptions, hang-ups and aggravations associated with the whole health history system…. if there even is a system.  To help debunk the health history conundrum, let’s look at the who, what, when, where and how of the patient’s health history.Who? 

    Who needs a health history? Every patient that is seen in the dental practice must have a current health history.

    Who needs an updated health history?  Every patient, before every service rendered.

    Who reviews the health history?  The doctor reviews and signs the health history and the doctor notes any “red flags” in the patient health history that my affect the patient’s treatment.

    Who signs the health history?  The patient or THE individual responsible for that patient signs the history. The doctor must also sign the patient’s health history (or update) signifying that the doctor reviewed the health history.


    What should the health history cover? 

    • Presenting complaint.
    • History of presenting complaint, including investigations, treatment and referrals already arrangedWhat should a health history cover? and provided.
    • Past medical history: significant past diseases/illnesses; surgery, including complications; trauma.
    • Medication history: now and past, prescribed and over-the-counter medicines, allergies.
    • Family history: especially parents, siblings and children.
    • Social history: smoking, alcohol, recreational drugs, accommodation and living arrangements, marital status, baseline functioning, occupation, pets and hobbies.
    • Systems review: cardiovascular system, respiratory system, gastrointestinal system, nervous system, musculoskeletal system, genitourinary system.


    When should a formal (new or updated) health history be obtained? A complete formal “written” hard copy of the patient’s health history should be obtained for every new patient, without exception

    When should the health history be updated? An updated health history should be obtained for every subsequent dental appointment…. even if the patient has 2 separate appointments on the same day.  (Although unlikely, that patient could have taken a medication, done or experienced something that could affect the patient’s dental treatment between the first and second appointment on the same day.)

    When should a new written (formal) health history be obtained? This is a trick question.  There’s no set period.  The gathering of a new complete (written) health history would depend largely on the health of the patient.  If the patient has multiple maladies and/or on multiple medications with a lot going on with their health, it might be necessary to have a new formal health history every 3 months.  However, a healthy 25-year-old on no medications with no health issues may need only to update the health history every 2 or 3 years.  The bottom line:  repeat a formal health history as deemed necessary by the doctor after an assessment of the patient’s risks.

    When should the patient complete the formal health history? Before the patient’s appointment, at least two days.  Have the health history 2 days before the patient’s scheduled appointment would allow enough time to seek information from the patient’s other healthcare providers if necessary.


    Where should health histories be updated?Where should health histories be updated? Ideally, for both a complete health history, new and existing patients, and for all updates of old health histories, this information should be gathered, from the patient or responsible individual, virtually, at least 2 days and no more than a week before the scheduled appointment.  This can be achieved by sending the form(s)via snail mail or encrypted (HIPAA complaint) email enough ahead of time for the patient to return the history two days before the scheduled appointment.  (Little is more frustrating than having a patient present for treatment needing pre-medication prior to that treatment or blood thinner regulated, etc..  The patient must reappoint or be provided the pre-medication by the practice and then the practice must wait the prescribed period before initiating treatment.)

    Least favorable, when the patient arrives.  Who knows how long completing the health history will take and if the patient will need pre-medication of modifications to existing medications?


    How should be health history information be obtained, both complete and updated heath history? Using technology at the patient’s convenience with enough time, whenever possible to review, follow-up with additional requests for more information or clarifications and to give necessary instructions to the patient to address any health history concerns.

    New health histories and updates can be obtained face to face from the patient or responsible party before the patient is seen, but this is an inefficient, time consuming and frustrating process for the patient and for the practice.

    A few final why's I submit to you:

    • Why would you not streamline the process?
    • Why would you not utilize available technology?
    • Why would you not make it easier for the patient, the practice, and the doctor?
    • Why would you choose to work harder, not smarter?

    Learn more about improving office efficiency in our free guide:

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    Roy Shelburne

    Roy Shelburne

    Dr. Shelburne graduated from the University of Virginia (Charlottesville) with a double major in Biology and Religious Studies in 1977. He went on to graduate with honors from Virginia Commonwealth University’s Dental School and opened a private general practice in Pennington Gap, Virginia, in 1981. He has served as Secretary/Treasurer and President for Southwest Virginia’s Component 6 of the Virginia Dental Association and as a delegate to the Virginia Dental Association’s Annual Meeting. He and his family have served as short-term volunteer missionaries with the Baptist Medical Dental Missions International and on various Mission of Mercy projects in Virginia. In March 2008, he surrendered his dental license after being convicted of healthcare fraud and spent 19 months in Federal Prison. Dr. Shelburne is a nationally known speaker, writer and consultant whose passion is to prevent what happened to him from happening to anyone else. He shares candidly with his dental audiences about his mistakes, what he learned as a result, and how to avoid them.

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