Title: Full medical history completion at new patient clinics within the restorative department at the Edinburgh Dental Institute (EDI)
Abstract:
Introduction: The National Health Services’ Business Services Authority (NHSBSA) takes from the Department of Health and Social Care (DHSC), the British Dental Association (BDA) and indemnity organisations to help formulate guidance on how frequently a medical history should be updated. Their guidance is the following: “computerised records should keep a signed and dated baseline medical history questionnaire and be ideally updated every course of treatment, signed by the patient and clinician” (When should a patient sign a medical history form? Customer Self-Service [Internet]. faq.nhsbsa.nhs.uk. Available from: https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA-01895/en-us). Utilising this, an audit was conducted within the Restorative Department of the EDI aiming to assess whether 100% of medical histories have a full medical history that has been completed within the Electronic Health Record ((EHR) medical history tab in R4) at new patient assessment/first appointment.
Methodology: 98 patients were selected (January 2024 to November 2024) from all new patient clinics after a sample size calculation using Raosoft Inc. Three assessors collected information on whether the medical history tab was fully completed on the R4 software, which clinician grade this was and whether any updates or attempts were made at completing it at a later date. For reliability, an inter-rater reliability assessment was conducted.
Results: 50% of 98 patients had no full medical history form completed at initial patient assessment within the MH tab. Relevant medical history was often noted in the R4 notes section. 14% of forms had a discrepancy between the MH tab and the MH notes and 13% had no update of the MH tab for subsequent visits.
Discussion: A change was suggested to aim for improvement in compliance levels. To reach 100% compliance, nurse involvement was encouraged, and a new standard operating procedure (SOP) was discussed. On the R4 dental software, starting a new MH record within the tab prevents the clinician from leaving the page until the form has been saved. Additionally, an email was sent out to promote a workshop for those that may not be aware of the requirement of form completion and how to incorporate this with time efficiency.
Conclusion: The findings were discussed at a department meeting and a second cycle of data collection is expected to review for any improvement and determine if 100% compliance, whilst the gold standard, is currently an attainable goal.
