How Often Should You Update the Health History?

By Olivia Wann, JD

You can likely recall an experience where a patient forgot to tell you they had a heart attack or other major illness since the last time they visited your office. Good thing you took the time to make an inquiry of any changes in their health history! 

You must have a fully completed medical and dental health history on every new patient and returning patient before the doctor makes a diagnosis or provides any treatment. Have you been to a medical doctor lately? Many of the medical providers are using automated medical history updates using an iPad or the patient's own personal mobile device at each visit.

Question the patient about their medical history at each visit to determine if the health status or medication taken has changed. Be sure to note in the progress notes. The best risk management process is to obtain a patient signature attesting to the update, whether a regular signature or electronic.

If a patient is non-compliant with completion of a medical history, perhaps these individuals are not the type of patients you need in your practice due to the risk of liability.  

Don't forget to revise your documents when the pediatric patient turns 18 and obtain a new patient registration and medical history.