In dentistry, it’s common to have patients fill out a medical history listing prior concerns, allergies and current medications. We are curious about what our patients are interested in for dental goals and what has occurred in their past.

As our patients cycle through years of preventive care, updates to the medical history commonly take the form of a dated signature stating nothing has changed. Your new medical patients seeking care for sleep disordered breathing (SDB), present new levels of complexity of medical evaluation.

Even people you have seen for years as dental patients are new to your medical practice. This gives you and your staff an opportunity to set new expectations and a fresh approach as you begin a new aspect of your relationship.   There is also a legal requirement to perform a proper history and physical in order to treat a patient for a medical condition. The insurance companies assume documentation of certain prescribed details and lack of documentation is grounds for withholding or reclaiming payment.

However, there are straightforward ways to add the elements of examination codes to your practice.  Over a series of articles I will walk the dental office through the process of Building the Medical Examination. These examination details were adopted by the Center for Medicare and Medicaid Services (CMS) in 1995 and 1997 and are used universally to define what makes up a medical record.

By adopting what you will see in the series, you can be assured that your records will not only pass inspection by any outside entity, you will also be able to communicate with your patients’ other medical providers using common language. This will ensure your status as a worthy member of the collaborative team. Steve Carstensen, DDS [ www.stevecarstensendds.com ]