Audit 01-01-06-041966- An audit of medical history recording
Introduction
Medical history recording is an essential part of patient care in dentistry. The patient’s medical history will allow clinicians to determine modalities of treatment, determine which procedures are safe for our patients and if referral to other clinicians in secondary care is appropriate.
Medical history questionnaire forms are used every time patients attend for routine examinations and should be updated as regularly as possible. We ask our patients to update their medical histories every 6 months.
We found on many forms that details have been omitted and that our existing form lacked any guidance for patients regarding alcohol and tobacco use. We were eager to improve our knowledge of our patients’ habits. We felt that improvements could be made in gaining other important medical information from our patients.
We hoped to improve our medical history recording to be able to meet our patients’ needs more successfully and treat them safely. The audit should help us advise our patients better with regards to smoking and alcohol use and thereby improve patient care.
Criteria
The criteria to be measured from medical history questionnaires are as follows
- Presence of a medical history
- Signature and date
- Medical history updated in last year
- Personal details recorded (name, address, postcode, DOB, telephone no.)
- Recording of any medications
- Smoking history recorded
- Alcohol use recorded
Standards
No definitive standards are available. Guidance is available from several sources regarding the standards we aim to achieve. The criteria identified above incorporate elements of the standards set out by both the FGDP and the BDA.
Ideally 100% compliance for all criteria is the goal, although this may not be achievable in day to day practice. A MINIMUM level of 90% compliance is expected at round 2 of data collection, with exception of criteria 1.
For criterion 1, at the end of round 2 a compliance level of 100% is expected.
If the patient has omitted an entry then compliance has not been met.
Method
Data for both rounds were collected using the form shown.
The first round of data was collected retrospectively. Each dentist picked 75 patients who had attended the practice in the 3 months prior to the audit.
The data was then analysed.
We then held a meeting to discuss the findings from the first round of data collection with all staff.
We discussed ways in which we could improve compliance and decided what we would change to achieve this.
The practice had been trialling a new medical history form around the time of the audit, so two different forms were being used during the 3 months prior to the audit.
The decision was made to change the medical history questionnaire we were using. We chose to use exclusively the NHS Lanarkshire form as it was more comprehensive than the previous one and included guidance for patients regarding tobacco and alcohol use (explanation of units, etc.). It was easier to update and has more space for personal details such as phone numbers.
Following the change of questionnaire form, data was then collected from a further 75 patients by each dentist.This data was collected over a period of 3 months until the sample size had been met.
All staff members were involved, making sure everyone knew of the changes made. We strove to ensure patients were more involved in filling in medical history forms, and patients were offered assistance if unsure how to complete the form.
The data from round 2 was then analysed and this report was produced.
Results
Round 1 and 2 data are shown on the chart below.
After collection and analysis of round 1 data it became clear where our shortcomings lay.
Although medical histories were available and generally being filled in, they were not being updated frequently enough. Information regarding smoking and alcohol was clearly lacking.
The data from round 2 shows an improvement in all areas, particularly the criteria of smoking and alcohol use. Medical histories were also being updated much more frequently.
The improvements have met the compliance levels expected of 90% and 100% for criterion 1.
Discussion
The results have shown clearly that prior to the audit the recording of alcohol use and smoking habits were below the standard set out. Medical histories were also not being updated physically as often as they should. In some cases we perhaps had verbally confirmed patients’ medical histories but had not recorded changes on the forms. In some cases, changes to medications etc. were entered into the patient’s computer records.
It is sometimes the case that patients are unable to fully fill in forms, whether due to poor eyesight or other disability. We try to gain as much information as possible when the patient cannot fill out the forms, often asking carers or family members to help. Liaison with GMPs is often necessary to ascertain particular medical information.
The medical history questionnaire previously used was lacking in that some patients were unsure how to comment on smoking and particularly alcohol consumption.
We found the new form more acceptable for patients as it describes what alcohol units are. It also allows the patient to update any changes more easily. I feel that some patients may be uncomfortable discussing alcohol and smoking and the form possibly makes this easier.
The practice as a whole have been much more active in ensuring forms are completed. Generally the process has been well met, although we encountered some resistance from patients who felt they were “always filling in more forms”. We find the new form easier to update, and the patient can now simply sign and date each time their details are confirmed.
The practice is now considering introducing a new form with more emphasis placed on social history. It may include eating and drinking habits, satisfaction levels regarding aesthetics, etc. Several forms have been assessed for suitability.
Having more accurate information regarding patients’ social habits, not only drinking and smoking, is essential for good patient care. This allows us to educate patients about detrimental effects such as oral cancer, liver disease etc. Smoking cessation advice should be given to those patients who smoke, or referred to the pharmacist for more guidance.
I have found the audit has made me more proactive in ensuring medical histories are properly completed, regularly updated, and discussed with the patient if they have any difficulty completing one.
Acknowledgements
Thanks to all staff members who participated in gathering data for the audit. There was certainly a lot if filing involved!
References
BDA , FGDP guidance regarding standards
Appendices
See attachments- data collection tools, old and new medical history questionnaire forms.