By Daniel J. Schulte
MDA Legal Counsel
Published in the July 2006 issue of the Journal
Question: I have no standard system or practice for completing or updating health history forms for my patients. Is there a legal requirement that a health history form be completed for each patient? How often should health histories be updated? Are these forms a part of the dental treatment record? How long must I hold on to them?
Answer: There is no Michigan law requiring that health care professionals have a completed health history form on file for each patient. Nor is there any precedent-setting Michigan case law that would impose such a requirement.
Michigan Administrative Code Rule 338.11120 is the only law that speaks to what must be included in a dental treatment record. This Rule does not require that a health history form be obtained and made a part of the dental treatment record. Rule 338.11120 mandates only that the dental procedures performed, the date the procedures were performed, the identity of the dentist or auxiliary personnel performing the procedure, the date, dosage and amount of any medication or drug prescribed, radiographs taken in the course of treatment, etc., be included.
Still, it is a wise practice from a legal perspective to obtain health history forms. Always remember that even in the absence of a specific legal requirement contained in a statute, administrative code rule or case law, dentists and other health care professionals are always going to be held to the standard of practice applicable to their profession. This standard of practice is established by the health care professionals themselves — not the Michigan Legislature or the courts. Indeed, it is likely that in a malpractice, licensing or other proceeding, the standard of practice of the dental profession would dictate that a health history form be obtained from each patient upon their initial visit to your office and prior to any treatment being provided or diagnosis being made. It is also likely that periodically updating your patient’s health history form would be required to meet the standard of practice.
Precisely how often the health history form should be updated is difficult to quantify, because the facts and circumstances of each case will be different. However, from a malpractice standpoint it would be wise to have a procedure in place ensuring that patients are asked on each visit about health history changes they may have experienced. Of course, if you have knowledge of specific health conditions that you know will affect your diagnosis or treatment decisions (for instance, a history of heart trouble, rheumatic fever, medications, the presence of allergies, etc.) you should be sure to ask for updated information regarding these conditions.
The fact that you asked these health history update type questions should be documented in the dental treatment record along with the patient responses. There is no Michigan statute that defines "treatment record." It certainly is conceivable that a health history form would be considered a part of the treatment record due to the fact that the information contained on the health history form is used by the dentist in the process of reaching a diagnosis and providing treatment.
I believe it wise to consider health history forms as part of the dental treatment record. Since these forms are a part of the dental treatment record, Michigan Administrative Code Rule 338.11120(3) requires that they be maintained for not less than 10 years from the date of the last treatment provided.
If you are interested in obtaining a sample health history form for use in your practice, the MDA offers a form that can be downloaded from the MDA website.