Improving Medical History Recording: A Dental Case Analysis

This report addresses the critical importance of accurately recording medical history in healthcare, particularly within dental practices. It presents a case study where a patient, Raghav, on anticoagulant medication (warfarin), experienced severe bleeding following a tooth extraction due to a failure in properly recording and communicating his medical history. The report identifies issues of professional responsibility and accountability within the oral medicine and radiology department, as well as the intern performing the extraction. Solutions discussed include emphasizing professional accountability, thorough documentation, and the importance of trained medical professionals handling critical cases. Recommendations focus on improving diagnosis through detailed medication history assessment and ensuring adherence to medical history protocols. The document emphasizes the need for dentists to obtain comprehensive patient information, including current medications and past medical history, to prevent medical emergencies and provide appropriate, customized care. This assignment is available on Desklib, a platform offering study tools and resources for students.

Importance of recording
medical history

Table of Contents
Introduction......................................................................................................................................3
Overview..........................................................................................................................................3
Problems..........................................................................................................................................4
Solutions..........................................................................................................................................5
Recommendations............................................................................................................................7
REFLECTION.................................................................................................................................8
CONCLUSION .............................................................................................................................10
REFRENCES ................................................................................................................................11

Introduction
Diagonis is the first step before starting any treatment. “The medical history or case
history of a patient is information gained by a physician by asking specific questions, either of
the patient or of other people who know the person and can give suitable information, with the
aim of obtaining information useful in formulating a diagnosis and providing medical care to
the patient” ( Wikimedia, 2021). Dental questionnaire asks so many general health questions –
it's because certain medical conditions and medications can pose health risks during dental
treatment – so fully disclosing your health history is a crucial step to receiving responsible
customized care. The ADA recommends that patients be asked whether their health status or
medication use has changed at each visit. It should be documented that the patient was
questioned about any changes to his or her medical history
I am going to present a case of accountability issue that I faced in my hospital. The
patients are first diagnosed in the department of oral medicine and radiology, where the doctors
inquire about their medical history, including current medications and any previous dental or
medical surgery. The patients are then referred to various departments based on their treatment. I
was assigned to the oral surgery department. Patients were assigned to us by the senior staff and
we used to perform extraction under their guidance. And the first step we had to do before
extraction was to take medical history of patient again.
Overview
One of my friends Simran was allotted an old patient named Raghav. Simran checked the
medical file of Raghav and found him in a suitable state for his extraction to be done. Simran did
extraction of Raghav following all the guidelines of extraction. He gave a post extraction cotton
pack to Raghav but later he found that Raghav bleed badly. He was stressed looking at the
condition of the patient. He called the senior doctor for help.
The senior doctor managed the patient by giving him by local haemostatic agents and
suturing. Later when the bleeding stopped it was found that Raghav was on warfarin which is an
anticoagulant.
This medication is used to treat blood clots and to prevent new clots from forming in your
body. Preventing harmful blood clots helps to reduce the risk of a stroke or heart attack. Warfarin
may put the patient under a risk of bleeding following surgical procedures like extraction.

The problem was brought to the attention of the Hod, who explained to Simran the
significance of keeping track of his medical history. He also sought advice from the departments
of oral medicine and radiology about their mistake.
It was the professional responsibility of oral medicine and radiologist department to take
proper medical history of Raghav and the send him to the required department for his
treatment. Even it was the professional responsibility of Mds staff and the intern
performing extraction to ask about medical history of the patient. This indicates medical
negligence of the doctors treating the patient. The patient comes to doctor with full trust
that he will be treated well and the treatment would not cause any harm to him. It is the
duty of doctors to ask patients to stop the anticoagulant medication of the patient before
the extraction.
Problems
While analysing case study details, it has been found that professional responsibility of
oral medicine and radiologist department regarding treatment was not followed properly. It has
been found that Raghav medical history was not properly assessed by the medical professionals
upon which it indicates accountability issue. Problem when assessed, has been identified that
Raghav was on warfarin which is an anticoagulant, and is used to treat blood clots and prevent
new lots from forming. The medical history of patient was not tracked properly by intern Simran
and the department of oral medicine and radiology about their mistake. Patient comes to doctors
to be treated well with proper medication, upon which it was the responsibility of oral medicine
and radiology department professionals to keep proper track of medications already being taken
by patient (Aubin, Hebert & Eurich, 2019).
The patient was not advised to stop anticoagulant medication of the patient, before
extraction and also it has to be properly assessed regarding proper new treatment which needs to
be given. Furthermore, it can be analysed that Raghav medical history was not assessed properly,
which was negligence issue on side of medical professionals handling the treatment. The
problem was also that Simran, intern handling case of Raghav did not take proper professional
guidance from senior doctors while tooth extraction, upon which it can be analysed that proper
guidelines and medical accountability principle was not followed (McKeeby & Coffey, 2018).
The dentist handling Raghav treatment was not specific regarding medical history
assessment of patient, where diagnosis of previous medicines was not done within case study.

Recording medical history plays high essential role in treating patients based on their proper
functional working scope to develop strengthened rise within medical conditions. The medical
history of patient enables to gain complete information about drugs and medicines which are
already being taken by patient, which further enhances abilities for professional medical care
being given within dental treatments.
Dentists need to gain certain informations regarding medical conditions, medications
which can pose health risks during dental treatments, which discloses health history within
customized care aspects significantly. Problem regarding case study analysis, also heads on
specific focus on fact that accountability among working professional principles within medical
history assessment plays strong role for providing treatments to various patients (Torres-Urquidy
& Powell, 2019). There was sheer case of negligence, and avoidance of accountability principle
among medical doctors who were handling case of Raghav regarding tooth extraction.
Importance of maintaining proper medical history of patient holds huge importance for proper
timely check of treatments, being delivered and also further keeping specific check. Case study
has highlighted problem of negligence about medical history of patient, which further led to
bleeding in tooth . There has been significant reduced efficiency, where medical staff was at
fault for not considering medical history of patient.
Solutions
Accountability on both a personal and professional level is critical in health care.
“Accountability means having to be answerable to someone for meeting defined objectives”
(Emmanuel & Emmanuel, 1996). The lack of clear responsibility and accountability in most
health-care systems undoubtedly contributes to health-care issues. These issues can be resolved
by being accountable, responsible and by performance measurement. There are many issues in
health care and lack of recording medical history is one of the major issues (Geleris, Shih, &
Logio, 2019)
Quote from Rosen Book :
“ Important past medical history includes baseline health and mental status, previous heart, lung,
renal or malignan disease, haemorrhage, infection and risk factors for coronary artery disease
and pulmonary embolism” (Hockberger & et.al, 2013).

“ The past medical history is critical in stratifying risk, congestive heart failure is a key
determinant of increase short and long term mortality in setting of snycope prior coronary artery
or cerebrovascular ” (Hockberger & et.al, 2013).
Underestimating the importance of sharing vital information limits your dentist's ability to be
prepared for any situation and recognise the significance of certain medical symptoms (Chen,
2021). Blood-thinning medication and oral extractions do not mix and a patient must stop taking
their medications in preparation for an extraction appointment and then resume taking them after
the required amount of time has passed.
Professional accountability
Recording medical history is a crucial step before any dental treatment. A patient's
medical history is a vital part of his or her dental history and increases the dentist's awareness of
diseases and medication which might interfere with the patient's dental treatment.
As per the views of Leventi & et.al, (2021) professional accountability holds huge
importance in developing proper medication and treatments further among patients dental
treatments, which further should be given high significance. Doctors should keep provide dental
record, consisting of documents regarding patient present medication, treatments provided and
the essential facts for recent condition. For keeping proper check on medications doctors should
have professional detailed knowledge regarding medication already taken by person, which is
one of the most essential element in dentistry treatments. It helps in identifying conditions that
may affect dental treatment, highlighting risk of patient experiencing medical emergency which
also further aids in diagnosis of oral manifestations of systematic diseases. Patients should give
clear information regarding specific medication being given, and also make sure that there is no
negligence from professionals. Research within recent study, also specifically heads on focus
towards fact that within case study assessment there was negligence from side of doctors of oral
medicine, radiologist handling treatment of tooth extraction (Price & Cohen, 2019).
However, as per the views of Malone, (2020) recent research also shows specific focus
should be also given to only trained medical professionals being given the responsibility to
handle critical cases. This further will make sure that extended adherence to legal accountability
factors for medical expertise holds crucial importance to signify further improvement which can
be done within patient treatment. Professionally qualified having productive knowledge of all

aspects, crucial to conduct treatments effectively of al patients will make sure that further
specific competencies is evolved.
As noted by the views of Zysk (2017), designing and adjusting treatment plan of patient
is another solution, which holds high importance for strengthening new functional treatment
availability and developing proper significant medication as per situation aspects. It can be
analysed that by providing proper care, and treatment plan of patient with specific focus on
optimum medication standards medication can be given with high correlation to medical history.
Dentists also have responsibility to make sure patient coming for any treatment, tooth extractions
should be functionally given proper care. Also trained medicals should be given the
responsibility to design treatment plan of patients, and medications further prescribed which will
make sure all procedures are legally followed. This can be also analysed that by designing
medication specifically enhances functional approach for making further treatment of patient
convenient, which will make sure that proper accountability is there. Designing and adjusting
treatment plan will further develop proper consistency, and maintenance of medication history
further synchronizes treatment availability.
As per the views of Arnold. (2017). it has been found that professional accountability
hods huge importance within medical history assessment of patients, where it enables to keep
proper details regarding further treatment being given to patient. Also medication specifically
inbuilt specific aspects to develop crucial strengthened vision, where there should be proper
primitive rise given to accountability regarding treatments. Recent research done in studies, also
heads on specific focus to the fact that adherence to medical history diagnosis should be properly
done by experts handling treatment of patients. There should be proper analysis done of
medications already being taken by patient, any side effects if any should be also further
discussed with medical professionals for keeping high accountability attached. It also heads on
specific adherence to principle of accountability, where patient medication should be discussed,
and proper assessment of already medicines being taken plays active role. This further will
enable treatment to be done in proper format, enhance overall efficacy significantly and generate
medical efficiency at pace. Oral medicine should be given to patient, considering medications
already being given by doctors and also making specific arrangements regarding anticoagulant
which should be stopped by doctors before extraction (Zhang & et.al, 2021)

Recommendations
There are further varied recommendations, which can be analysed to further formulate
proper new medical aspects where medical history diagnosis should be functionally focused on
among dentist treatments. Recommendations for further improvement in diagnosis, medical
history assessment can be done by further heading on extended parameters where accountability
should be followed actively. While handling treatments, of tooth extractions doctors should take
prior information in detail about medications and past history assessment of patient. It can be
also analysed that dentists must also make sure that proper diagnosis is done by experienced
senior doctors, where medication should be also analysed properly. This further also heads on
specific focus on aspects, where doctors must also maintain proper record of patient previous
treatments taken which will make sure that adherence to legal factor is being done. Also patient
medical history should be further focussed on where head of all departments must be specific
crucial regarding accountability aspects. The doctors by keeping adherence to leadership among
professional doctors, and medical expertise handling cases will be able to make sure that
treatments are being given properly.
Using medical code of conduct, principles will make clarity within accountability in
medication done more effectively among dentist treatments. It can be also analysed that by
adhering to professional standards, accountability will be done more diversely further advancing
scope towards proper treatments being given to patients. The professional consistency and
competencies towards medication should be also supervised by professionals having detailed
knowledge regarding treatments and accountability. Furthermore, by keeping proper check on
prescribed medication, patients medication history should be also saved and kept within
systematic diagnosis aspects for maintaining proper effective services being delivered. This
further holds high importance, on which doctors and medical experts should also evolve rise in
training interns about oral medication where medical history assessment further plays critical
role for making treatment done effectively (Liddell & et.al, 2021)
If any patient is having any medication before treatment, there should be technical focus
evolved and developed maintained for keeping check on extensive functional accountability. The
principles of accountability, and maintaining proper significant reliability among treatments by
dentists will make sure that there is no side effect on patient healthcare. Patients assessment,
shall be done by organizing proper appointment with them by senior doctors and to further keep

significant focus on keeping record of all medications. Patients should be further prescribed new
treatment, only after assessing the competencies where detailed advancement regarding
leveraged specific efficacy shall be maintained. There should be proper competent focus adhered
on maintaining significant reliance on maintaining proper records of medical history of patients.
REFLECTION
In the present case of Simran and Raghav the aspect of accountability is highly important
and play an important role at the hand of Simran because ignoring the medical history of the
patient and by the Simran and the radiology department is wrong at both the hands because if the
patient would be infected and cause any severe harm then the question would be raise towards
the hospital too. Here servant leadership would not be applicable wherein it is assumed that the
follower would know everything and the job would be performed at the best level. This would
raise the question of accountability that if the mistake would be committed then who will be
responsible for it. However, the issue of accountability would be resolved and deal with the
transformational leadership wherein mentorship play an important role (Rooke, 2018). This is
because the entire work and the role would be made performed in the mentor wherein the chance
of the mistakes are low and the accountability issues would be lied towards the mentor. Also as
per this leadership style the mentor would closely work with the follower and make a close
observation that would lead to assist an important role in understanding the follower and its
capabilities which would be reduce the chances of the mistakes. This will play an important role
in the field of medical and the present case of Simran because here with a small mistake the
question of accountability would be raised towards the doctor and the hospital.
From the aspect of transformational servant leader ship various aspect and skill is being
learned that may lead to play an important role in the present case. Inspirational motivation is the
major aspect that can be learned from the transformational servant leadership because when a
follower would get an exposure of the leader then it will not only lead to motivation but at the
same time would also insist to learn and guidance that would lead to reduce the chances of the
mistake (Hadi, & Tola, 2019). Since transformation leadership is related with exposure of the
leader with the follower that would lead to insist the follower to develop the new ideas and
thinking which would reduce the chances of the mistakes. In the present case of Simran this
leadership would be applicable wherein if it got a regular guidance then the mistake would never
be caused and the aspect of accountability will rise towards the HOD and the hospital.

This can be directly implacable in the present case because with the aspect of
transformational servant leadership communication is the central focal point and in the present
case as well as in medical field an effective communication would lead to play an important role
in terms of sharing of the patient information and the exposure of the medical history of the
patient so that the most suitable and effective treatment would be given and enabled to the
patient. Likewise, in the present case too with the aspect of effective communication between the
patient and the doctor the best medical service would be enabled to the Raghav and the situation
of blooding and the involvement of HOD and senior doctor would never arise.
CONCLUSION
The report has concluded detailed analysis of significant importance of recording medical
history, where patient medications already being taken further formulates specific focus on
accountability aspects. Doctors and medical experts, as per legal and professional standards must
adhere to obtaining informations about formulating diagnosis about medical care being given to
patient. The study also concluded case study, where previous medical history of Raghav was not
taken specific focus by the intern Simran for tooth extraction which led to excessive bleeding.
Research further also summarized specific factors where accountability standard has been
lacking, which plays crucial importance for treatments to be done with high accuracy and also
maintenance of medical history.
The research has summarized analysis of leadership within adhering to legal standards,
and maintaining proper focus on accountability to patient when they come for treatments. It has
been also found that report has further developed significant factors worked on, upon which
medical experts and doctors must also make sure that interns are trained about effective
medication practices along with accountability aspects connected further. Importance of
recording medical history signifies functional working growth to be aligned with expertise being
evolved in treatment, which further holds crucial role for maintaining patient comfort in proper
recovery from dentist treatment

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