Chapter 5. MEDICAL HISTORY OF DENTAL PATIENT

SECTIONS OF MEDICAL HISTORY

Medical history (or case history) is the main document to describe patient status and treatment. At large multidisciplinary clinics each patient has his own medical history, in which there is complete information about his condition, methods of treatment, etc. This is important for interdisciplinary cooperation and effective treatment of patients.

Medical history is a legal document, it should not be given to the patient. This document is stored in record department for 5 years. If after five years the patient does not come to the doctor, his/her history is given to the archive for long-term storage.

Medical history usually includes:

► personal profile;

► informed consent;

► health questionnaire;

► medical part;

► progress notes.

PERSONAL PROFILE, INFORMED CONSENT,

HEALTH QUESTIONNAIRE

Personal profile is filled in by the receptionist when the patient comes to the clinic for the first time. Every medical history is assigned a serial number, which is registered in a computer database and/or in a special Record Book of Primary Patients. Sections Name and surname, Date ofbirth, Address can be filled in only with a document confirming the patient's identity (passport or military ID card).

Informed Consent and Health Questionnaire are filled in by the patient himself or his/her legal representative. The text of Informed Consent and questions in Health Questionnaire could vary in different clinics. Examples are given in fig. 5.1 and 5.2.

Fig. 5.1. Informed Consent text variations

Fig. 5.2. A variant of Health Questionnaire

MEDICAL PART

Medical part is filled in by the dentist during the patient's first visit; progress notes are entered by the dentists after each appointment. Medical part consist of the following sections: