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Accurate and up-to-date medical histories are at the heart of safe and effective dental care. The medical history underpins many of the decisions clinicians make – from prescribing medication and choosing local anaesthetic to planning treatment. This recent audit at a foundation training practice in Bristol sought to evaluate and improve compliance with this fundamental aspect of record keeping. The results demonstrate how small, targeted interventions can drive significant change – not only improving documentation but also strengthening a culture of patient safety and teamwork.
The General Dental Council (GDC) Standard 4.1.1 states that: dental professionals must “make and keep complete and accurate patient records, including an up-to-date medical history, each time that you treat patients.”1
This standard exists for good reason. Having a current medical history enables the dental team to identify systemic risks, avoid contraindicated medications, and plan appropriately for patients with complex needs. For example, those taking anticoagulants may require additional haemostatic measures following extractions, while individuals with certain cardiac conditions may benefit from antibiotic prophylaxis. Some patients may benefit from tailored treatment scheduling based on their medical history – for example, the Scottish Dental Clinical Effectiveness Programme (SDCEP) guidelines recommend treating a patient who is at higher risk of bleeding after a dental procedure in the morning.2
At a foundation training practice in Bristol, an internal audit was designed to assess whether clinicians were consistently updating medical histories at every appointment, in line with GDC standards. Six clinicians were in active practice at the time.
A random sample of 100 patient records was reviewed. If the medical history was updated or confirmed on the day of the appointment, the case was marked as compliant – if not, it was recorded as non-compliant.
Cycle 1 revealed that only 37% of records met the required standard, highlighting a considerable gap between expected and actual practice.
Figure 1: Cycle 1 results
To address the findings, discussions were held with clinicians to understand why compliance was low.
Several common themes emerged:
Verbal updates, but incorrect documentation: Some clinicians were asking about medical histories but failing to record this on the appropriate tab in the software.
Delegation assumptions: Others assumed dental nurses were responsible for updating records after they were verbally checked by the clinician.
Pre-appointment forms: A few believed that every patient would have already updated their medical history on the online pre-appointment forms before coming to their appointments.
Unclear frequency: Some thought updates were only required at recall appointments rather than every visit.
These insights made it clear that the issue was not a lack of concern for patient safety but rather ambiguity in workflow and responsibility.
Drawing on evidence-based strategies from Foy et al.3 and Ivers et al.4, feedback was structured to maximise its impact. The literature shows that feedback is more effective when delivered by a peer or supervisor, reinforced by explicit goals, and followed by an action plan. My educational supervisor (also the principal dentist) and I delivered the feedback. Each clinician was shown the Cycle 1 results and reminded of the GDC standard regarding the medical history. Dental nurses were briefed in a team meeting and reminded via text communication to check that the clinician had updated the patient’s medical history at every appointment.
The collective message was clear:
Medical histories must be updated or confirmed at every appointment – regardless of appointment type.
It is the shared responsibility of both clinicians and dental nurses to uphold this GDC standard.
The interventions were deliberately simple: improve awareness, clarify roles, and use existing systems correctly.
After implementing these changes, the audit was repeated using another random sample of 100 records.
Cycle 2 (as shown in Figure 2) demonstrated a vast improvement – 92% compliance, with only 8% of cases remaining non-compliant.
Figure 2: Cycle 2 results
While this audit showed a positive improvement in medical history record keeping, the medical history update rate should be 100%. This highlights the need for re-audit. Additionally, the accuracy and completeness of those updates were not assessed. Future cycles could explore whether the information recorded is consistently detailed and relevant. This might include cross-checking the recorded history with a post-appointment patient questionnaire to verify accuracy.
Another consideration is sustainability. Behavioural improvements often regress over time without reinforcement. To maintain progress, regular mini-audits and reminders during team meetings are essential. Embedding prompts within clinical software – for instance, automated alerts when a medical history has not been reviewed within a certain timeframe – could also provide further support.
This audit demonstrated that improving medical history compliance hinges on clear communication, shared accountability, and regular feedback.
It also highlights how audits – when led by clinicians within their own practices – can directly translate into measurable improvements in patient care. The process fosters ownership, transparency, and a culture of continuous learning – all hallmarks of safer dentistry.
For practices looking to replicate this approach, several steps may help:
Start simple: Focus on one measurable behaviour, such as ensuring medical histories are updated at every appointment.
Engage the whole team: Include clinicians, dental nurses, and reception staff.
Provide constructive feedback: Share results openly but supportively, focusing on solutions rather than blame.
Set clear expectations: Reinforce standards at meetings and during staff inductions.
Re-audit regularly: Periodic reviews sustain engagement and prevent deterioration of standards.
While this project was conducted in a single general dental practice, its findings may resonate across the profession. Many practices rely on verbal routines or assume that digital systems are automatically updated, creating potential safety gaps. We hope that the findings of this audit will encourage other practices to carry out a similar audit, to ensure patient safety and compliance with regulatory requirements.
From 37% to 92% compliance, this audit shows that meaningful improvement is possible through small, evidence-based changes. The transformation was achieved without new software, funding, or external oversight – simply through effective feedback, leadership, and team collaboration.
The project serves as a reminder that patient safety relies on habits as much as on systems. Every time a clinician opens a patient’s record, there is an opportunity to safeguard care through one simple act: checking and updating the medical history.
Sustaining this success will depend on continuous reinforcement – through meetings, induction training, and future audits. But even at this stage, the results illustrate a clear message for dental professionals everywhere: when we prioritise communication and accountability, safer dentistry follows naturally.
References
General Dental Council. Standards for the dental team [Internet]. London: GDC; 2013 [cited 2025 May 13]. Available from: https://standards.gdc uk.org/pages/standards.aspx
Scottish Dental Clinical Effectiveness Programme. Management of dental patients taking anticoagulants or antiplatelet drugs [Internet]. 2nd ed. Dundee: SDCEP; 2022 Mar [cited 2025 Jul 15]. Available from: https://www.sdcep.org.uk/media/ypnl2cpz/sdcep management-of-dental-patients-taking-anticoagulants-or-antiplatelet-drugs-2nd edition.pdf
Foy R, Skrypak M, Alderson S, Ivers NM, McInerney B, Stoddart J, et al. Revitalising audit and feedback to improve patient care [Internet]. BMJ. 2019;364:k4027 [cited 2025 Jul 15]. Available from: https://www.bmj.com/content/364/bmj.k4027
Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard‐Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes [Internet]. Cochrane Database Syst Rev. 2012;6:CD000259 [cited 2025 Jul 27]. Available from: https://doi.org/10.1002/14651858.CD000259.pub3
