Is Your Preanesthetic Medical History Form State-of-the-Art?
How long has it been since you updated your preanesthetic medical history form? Most busy dentists are happy with their history form and perceive no reason to change it. However, an antiquated and/or incompletely filled out preanesthetic medical history form can be a very costly mistake. Lack of documentation of critically important information cannot only alter patient outcome but can place the dentist in a totally defenseless position if an untoward incident were to occur. The plaintiff's attorney will ask, “Why didn't you obtain a medical consultation?” The defense attorney will hope that the answers are documented in the dentist's history form.
No form is perfect or all-inclusive. The limited information recorded on any form is only as good as your personal notations to follow-up questions related to the patient's positive and/or blank responses. The plaintiff's attorney will always ask about any question that is left blank and will imply that the dentist didn't adequately evaluate the patient, even though the dentist may have verbally filled in the information gap.
As an example, every form asks about asthma, but many lack critical notations by the dentist of its severity. If your documentation does not include additional information on asthma (How serious is it? E.R. visits? Hospital admissions? What triggers it? How do you manage it? When was your most recent attack? Are you clear now?Did you take your medication today?), you will not be able to justify in court or at a dental board hearing your decision to proceed with administration of the anesthetic. The judge/jury/dental board hearing officer will have no way of knowing whether the patient had 4 serious asthma episodes just before the anesthetic was given, or whether the history of mild asthma is related to a 1-time episode 20 years ago. Even if the dentist obtained these answers to justify not referring a patient for a medical consultation, the information must be included in the written record if it is to be helpful in the defense.
Because of my experiences as an expert in cases where outcomes have been less than ideal, I recommend that you update your form to include several state-of-the-art preanesthetic items that may be lacking.
Coronary Artery Procedure
Because many myocardial infarctions can now be reversed with “clot-buster drugs,” balloon angioplasty, and/or placement of a coronary artery stent soon after the onset of ischemia, patients with significant coronary artery disease can truthfully deny a “heart attack” on an outdated form but still might be at risk because of additional arterial disease that is too distal to stent or bypass. If a stent was placed, the patient must remain on clopidogrel (Plavix) and aspirin with no interruption even for dental surgery until his or her cardiologist indicates that it is safe to stop. For uncoated stents, this may be a matter of months, whereas with coated stents, the minimum time to remain on these drugs is at least a year and perhaps forever. Without documentation that the patient followed the prescribed drug regimen, the dentist cannot possibly make an informed decision on whether it is safe to proceed according to current guidelines of the American College of Cardiology and the American Heart Association.1 If such a patient subsequently were to have a fatal perioperative myocardial infarction, even with local anesthesia alone, and if the dentist did not document that the patient had taken his or her antiplatelet drugs that day, the defense would be severely weakened.
Can You Walk Up a Flight of Stairs Without Stopping?
If the answer is yes, the patient's risk of cardiac morbidity/mortality related to noncardiac surgery is low because he or she has enough physical reserve to consume 4 or more metabolic equivalents of oxygen in performing physical work (1 MET is 3.5 ml of oxygen consumption/kg/min). The number of METS that the patient can generate is based on the Duke Activity Scale Index,2 with 4 METS being the break point for determining whether one should proceed with minor elective dental surgery without a cardiac consultation, when documentation states that the patient does not have an active cardiac condition such as unstable angina, myocardial infarction within 30 days, decompensated congestive heart failure, significant dysrhythmia, or severe valvular disease such as critical aortic stenosis.
Loud Snoring, Daytime Sleepiness, Obstructive Sleep Apnea
Obesity is rampant in the American population. Although obstructive sleep apnea does occur in normally proportioned patients, it is much more common in obese and morbidly obese individuals. In addition to the obvious potential for acute loss of airway patency, which cannot be corrected through the usual airway modalities such as head tilt-chin lift-jaw thrust and positive pressure with a face mask and bag, these patients are much more likely to have severe hypertension, coronary artery disease, pulmonary hypertension, chronic hypoxemia, hypercarbia, and decreased functional residual capacity. They also may be exquisitely sensitive to small doses of sedative drugs, despite their massive size.
Which Medications Were Taken Prior to the Appointment?
The dentist must document not only which drugs the patient has been prescribed, but whether or not the patient took them at the usual time prior to the appointment. In particular, beta-adrenergic blockers should almost always be taken on the day of the procedure, according to American College of Cardiology/American Heart Association Guidelines.1 A rebound hypertensive, tachycardic event may otherwise occur. Clonidine withdrawal also can lead to a rebound hypertensive crisis. Because as a general rule most medications should not be missed prior to administration of a dental anesthetic, it is important to document this in the record.
Once the history has been completed, the dentist must document findings of the following evaluations.
Mallampati Airway Classification
Loss of an adequate airway leading to hypoxemia, cardiac arrest, and irreversible brain damage is the most common adverse outcome associated with sedation and anesthesia. Therefore, the preoperative evaluation must include documentation of the Mallampati classification. While sitting erect, the patient must maximally open his or her mouth without phonating. The dentist evaluates the quality of the airway by noting the extent of various pharyngeal soft tissue structures that can be visualized. If the tonsils, tonsillar pillars, uvula, and glottis can be seen, the patient has a class I airway.3,4 A class IV airway in which only the hard palate can be observed is more likely to cause difficulty in emergency intubation and probably is more difficult to maintain if airway problems develop during positive-pressure ventilation attempts with a face mask and bag. The dentist must document the Mallampati class before administering any sedation or general anesthetic.
American Society of Anesthesiologists Physical Status Classification
After the state-of-the-art preoperative medical history has been completed and includes all the important adjunctive notations that would give any investigator a clear picture of the basis for the decision to manage the patient's care, the dentist must specify the patient's American Society of Anesthesiologists physical status, which includes 6 categories plus the designation of an emergency modifier. Although experts often will debate the proper classification for a given patient, it remains the standard of care to classify the patient using this scale.
The Patient is in Optimal Condition for the Planned Procedure
This is the summary statement that is prepared when all of the preoperative medical history has been evaluated and documented. It documents the dentist's rationale for deciding why a medical consultation is not necessary and why it should be safe to proceed with the dental procedure.
With a properly completed state-of-the-art preanesthetic medical history form, the dentist is thoroughly prepared to deliver optimal patient care. I urge you to review your form and consider these important revisions.