The importance of patient records in the dental office
The first consultation, in any dental office, should include the completion of a patient chart.
Even if it is not of great importance to the patient, or they often do not understand why they need to fill it in, it is of real importance in many ways and the provision of information should be taken seriously. The importance of completing the sheets lies in providing the following:
General medical history – this box usually appears immediately after the one containing personal and contact details.
In the ‘General Medical History’ section the patient will fill in all the general illnesses they are suffering from as well as any medication taken.
Also any surgery performed in the past should be mentioned.
This step is, in our opinion, very important because in this way we can find out crucial data that can decisively influence subsequent treatment plans.
Among the common pathologies encountered in patients we mention:
Hypertension – is the most common pathology, extremely common in our country.
In many cases, hypertension is not well controlled by the patient and dental surgery can result in heavy and prolonged bleeding.
Valvular insufficiency, previous heart attack, atrial fibrillation – the group of these pathologies is particularly important because patients suffering from these diseases are given anticoagulants.
The group of drugs known as anticoagulants influences bleeding during surgery, so that, in most cases, the cardiologist’s consent is needed before surgery and it is performed in specialized units.
Poorly controlled diabetes influences the quality of healing. Therefore, invasive procedures on diabetic patients should be concluded with the prescription of antibiotics to reduce the risk of infection.
The dental history is important to be mentioned because, in the absence of an X-ray at the first consultation, it will guide the doctor in getting an idea of the treatments the patient has undergone and their age.
The patient’s vices should be mentioned. Whether it is alcohol, drugs or cigarettes, these should be mentioned. For example, smoking contraindicates the application of implants because the healing rate decreases considerably and the risk of peri-implantitis appears.
Alcohol and smoking can lead to lesions or abnormal deposits on the oral mucosa.
Their identification and correlation with the above risk factors can lead to the formulation of a correct diagnosis and an effective treatment plan.
Allergies are a particularly important, life-threatening heading for the patient, any known hypersensitivity reaction should be mentioned here.
If the patient has never had anesthetics administered in the dental office, they will be tested to see if they are allergic to articaine hydrochloride, the most common anesthetic used in dental offices. Also, before prescribing antibiotics, the doctor must make sure that the patient has no allergies, otherwise the patient will be referred to a counterpart.
Patients can often be reluctant to fill in these forms. However, with good guidance, the patient will understand its importance and will take an interest in providing complete and factual information.
