Updating and entering a patient’s health history is a very important part of what your assistants and hygienists do during a patient’s appointment. Here are some tips you can share with them so that they can use the Dentrix Health History module more efficiently.
For your clinical team to be able to enter medical conditions, allergies, and medications, your office must first have a database of these items to select from. You’ll find that medical conditions and allergies are typically already in your system. Patient-reported medications will need to be entered in Health History. This gives your office the opportunity to decide how medications should be entered. For example, you could enter the brand name of the drug and use that for generic forms of the drug as well, or you could enter both brand name and generic drug names. Create a database for your practice based on the needs of your office and your doctors’ preferences.
Assigning Health History Items to Patients
You can enter medical conditions, allergies, and patient-reported medications individually by selecting the Health History item you want to attach to the patient from this list of options; or you can attach multiple Health History items to a patient at once by selecting the Add Multiple option.
Selecting to add an individual medical condition, allergy, or medication is a good option when you only have one item to enter.
But if you need to enter more than one medical condition, allergy, or patient-reported medication, use the Add Multiple option. This would be the best way to enter health history information for a new patient or a patient who has had a lot of medical changes that need to be entered. By using the Add Multiple option, your assistant and hygienist can save time by selecting all applicable medical conditions, allergies, and/or patient reported medications from a single location at once.
It’s important to note that if a patient has already been assigned a medical condition, allergy, or medication in their Health History, it will no longer be available on the list of medical conditions, allergies, and medications to choose from.
Inactivating Health History Items That No Longer Apply
You should work towards having a comprehensive health history for your patients. Train your clinical team to inactivate medical conditions, allergies, and medications that no longer apply to the patient instead of deleting them. This way you’ll have a record that this condition did apply to the patient in the past. When inactivating a medical condition, allergy, or medication, you have an option to add a note, which I would recommend. An example of a note on an inactivated patient-reported medication could be “Patient no longer takes blood pressure medication. Blood pressure is controlled through diet and exercise.” Be sure to include the date of the note and the initials of the staff member making the note.
Copying Health History Items to Clinical Notes
There is an option to copy the patient’s Health History to their clinical notes. This is a time saver for your clinical team when writing their notes because they don’t have to type in all the patient’s medical conditions, allergies, and/or medications. It also ensures accurate clinical notes because they won’t forget to enter anything into the clinical note. When copying Heath History items to a clinical note, you have the option of including only current items, or including inactive items as well.
Having an accurate health history for your patients is a critical part of their care. Share these health history tips with your clinical team so that they can enter health histories more efficiently.
For additional information, see the various topics under Health History Overview in the Dentrix Help.
By Charlotte Skaggs, Certified Dentrix Trainer