The anamnesis is one of the most important tools for dentists and orthodontists to identify illnesses at an early stage and to identify risk factors. But what exactly should you pay attention to when creating or revising your medical history questions?
What should the dentist's medical history sheet be considered?
When creating the medical history sheet, it is important that you not only ask questions about oral health, but also about the patient's general medical condition.
Reporting a heart condition or diabetes may also be important for you! For example, a diabetic's oral mucosa is more sensitive than usual and tends to become inflamed. With this knowledge in mind, as a dentist or orthodontist, you can optimally tailor the treatment to your patient.
For example, these illnesses or treatments are often queried in dentists' medical history sheets:
- Past heart surgeries
- diabetes
- Blood coagulation disorders
- HIV
- hepatitis
- Diseases that affect the cardiovascular system
- asthma
- epilepsy
- Drug intolerances
- allergies
In addition, it may be important to learn what circumstances your patient is living in. For example, stress and sleep disorders can trigger teeth grinding.
Written anamnesis
Normally, this data is classically combined with a Questionnaire made of paper or directly online queried. Clear information on medical confidentiality is important on the written questionnaire. It can also be helpful to have medical history sheets available in several languages.
Tip: You can also complete the anamnesis with Nelly in a time-saving and resource-saving way. The special thing about this: The questions are automatically translated into the patient's language. Medical history sheets made of paper in various languages are therefore a thing of the past!
Test the digital medical history sheet for dentists with Nelly now!
Oral anamnesis
In addition to the written anamnesis, you should ask a few additional oral questions. In the best case scenario, ask open-ended questions such as “What brings you to me? “Avoid questions that the patient can only answer with “yes” or “no.” This procedure is the best strategy for obtaining all relevant medical data and improves doctor-patient communication.
Anamnesis via eye diagnostics
Don't just rely on what the patient tells you. Instead, use your medical instinct to identify any illnesses simply by observing the patient. An example: Perhaps a cough can indicate an asthma, an infection or an allergy. This in turn allows conclusions to be drawn that could be important for your subsequent treatment!
Free medical history sheet dentist template
Despite all these tips, the initial conception or revision of the questionnaire can be difficult. That is why we have this medical history sheet for dentists creates, which queries all important details without being overloaded with unnecessary questions.
Free medical history sheet orthodontics template
For orthodontists, there are some special features to consider within the medical history sheets. For example, it is usually asked whether the patient has undergone orthodontic treatment before or whether x-rays of the jaw have been taken recently. We have these specific questions for orthodontists included in this orthodontic template for you.
Note: Both medical history sheets are actually used in dental and orthodontic practices — and are therefore more “tried and tested in everyday life” than the samples from the dental association!
What are the data protection rules for the medical history sheet?
The data collected during the anamnesis is very sensitive and, of course, kept confidential. As health data, you are subject to special data protection. No wonder, because: Health insurance companies and pharmaceutical companies in particular are interested in this data, which of course must not be passed on to third parties.
Attention: In fact, the breach of medical confidentiality can be Section 203 Criminal Code be punished with a fine or even imprisonment of up to one year.
In general, the following applies: Only data that is really necessary to diagnose or treat the patient may be queried. An inquiry about the profession or hobby, for example, is only permitted if these findings could actually influence the treatment.
Retention periods
In principle, medical history sheets from dentists and orthodontics must be kept for ten years after the treatment has been completed. These are minimum storage periods. In individual cases, it is even advisable to read the documents For 30 years to store. After this period, any liability claims made by the patient are time-barred.
Important: If you digitize the medical history sheets, you should definitely keep the original on paper. Because in case of doubt, no one can determine later whether the scanned document really corresponds to the original.
Digital medical history at the dentist with Nelly
It is better if you have your medical history taken online right away. It's very easy with Nelly's software. With a QR code, patients can Take anamnesis quickly and easily on your own smartphone. With a link on your website, you can even do this from home! Wir advise you without obligation and free of charge about your individual case.
The personal names used in this article always refer equally to all persons. Dual naming and alternate names are omitted in order to improve readability.
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