Medical History – Medical History
Medical History
A medical history is a starting point for a dialogue with a patient about their medical status. Only a select number of questions are usually included in a health questionnaire, but each affirmative answer should lead to additional questions, which are also provided for you.
The initial medical information can be obtained by various means:
- by a self-administered health questionnaire
- by verbal inquiry
- a review of systems will provide mostly subjective information that will assist in ascertaining the severity of a patient’s medical condition
- additional health data through a medical consultation
Assess a patient’s potential for complications:
The most common concerns that should be addressed to avoid medical complications are a patient’s:
- ability to achieve hemostasis
- susceptibility to infections
- risk for side-effects to drugs and drug interactions
- ability to heal after trauma
- ability to cope with stress
Assess the need for dental modifications to reduce medical complications:
- need for adjunct measures to achieve hemostasis
- need for antibiotic prophylaxis
- need for glucocorticosteroid replacement therapy
- use pre-medication to reduce anxiety
- use of sedation
- need to adjust the length of procedure
Assess the appropriate setting for treatment of a patient with medical complexity:
- out-patient in a non-hospital or hospital setting
- short-procedure unit
- operating room
Classification of a patient’s medical complexity:
American Society of Anesthesiologists (ASA) status classification. The intended use of ASA classifications is to assess a patient’s outcome from undergoing general anesthesia. It may not be appropriate to use ASA classifications to assess a dental patient’s risk from dental procedures using local anesthetics.
Medical Complexity Status (MCS) is a system developed especially for out-patient care to assess the risk of routine dental procedures.
Related Pages
- ASA Classification
- Consultation
- Medical Complexity Status
- Medical Health Questionnaire
- Review of Systems