Patient forms and recalls

Where the medical history stands

The clinical record's Medical tab opens on one line that says where the patient's medical history stands, from their newest medical history form:

The review period is the medical history template's Expires after (days) under Settings → Clinical templates → Patient forms. If the forms can't be loaded, the line says Couldn't check with Retry — never that the history is up to date.

Below it come the alerts in force today (a bell marks one that pops up when the record opens), then conditions, medications and allergies, then the forms. Type a name into the box under a list and press Enter to add it; the pencil opens the full form to correct a fact, the archive icon retires it, and Show archived brings retired facts back into view.

Patient forms

Templates are configured under Settings → Clinical templates → Patient forms. The practice starts with a Medical history form and ten consent forms (general, extraction, endodontic, crown and bridge, implant, whitening, periodontal, sedation, orthodontic and denture), each needing the patient's signature; the Defaults card there restores any that are missing. On the Medical tab, New medical history lists the templates; choose one to enter the patient's answers as they give them.

A field that asks for one raises a provisional alert straight away (for example an allergy the patient reports), so the front desk sees it before a clinician has looked.

Conditional questions

Some questions appear only after an earlier answer, as the form's template sets them: "Which blood thinner?" shows once "Do you take blood thinners?" is answered Yes. A question that is hidden is never required. If an answer was given and then hidden by changing the earlier answer, it is kept with the form but never raises an alert or proposes a fact; the review shows it greyed, as Answered, then hidden by an earlier answer. The patient's own page works the same way.

Forms by age

A template can be for some ages only (For ages under Settings → Clinical templates → Patient forms). New medical history, and the form picker of Send form link, list the forms for the patient's age first and the rest under Other ages. Choosing one of those asks why it is used for this patient, and the reason is kept with the form.

The patient's age is worked out in whole years on the day the form is chosen, in the time zone of its location: a birthday that day counts, and a birthday on 29 February counts from 1 March in other years. The age, that day and the location are kept with the form, so correcting the date of birth later changes nothing already recorded. A link keeps the age from when it was created, even when it is sent again.

Without a date of birth on file, every form can be filled in at the desk and no age is kept. A form link still needs the date of birth, because the patient confirms it to open the form.

Who signs

Who is signing? offers only the people who may sign for this patient today, worked out from their age and the parents, guardians and attorneys on their Family card. A treatment plan's acceptance follows the same rule.

The age of consent is 16 in the UK and 18 in the United States and Italy. The patient's age is counted on the day of signing where they sign: in the time zone of the location chosen in the form, or of the plan's location. Changing the form's location offers that location's signers.

• No date of birth on file: nothing can be signed. The dialog says to add the date of birth in Details first.
• Nobody on record for a child: the dialog says to add a parent or guardian in Details › Family first. Typing a parent's name is not enough: someone the practice has not recorded cannot consent for a child.
• A relationship ended in the meantime: recording is refused with That relationship can't consent for this patient now; choose the signer again.
• A parent, guardian or attorney who has been erased: they are no longer offered, and a signature under them is refused with This patient is no longer available; choose the signer again.

The signer is checked before the signature is filed, so a refused signature leaves nothing behind.

A child who can consent for themselves (UK only)

In the UK a child under 16 who fully understands the treatment may consent for themselves (Gillick v West Norfolk and Wisbech AHA, 1986). A dentist, hygienist or therapist linked to their practitioner profile can record that judgement: they choose The patient, judged able to consent under Who is signing? and confirm their password. The child signs, and the form records the clinician, their registration at the time and when they confirmed their password. It is never offered at a practice in the United States or Italy, and the front desk cannot record it.

The forms list, and the review, show who signed: Signed by Mark Doe (Parent), or for a judged child Signed by Jane Doe (14), judged able to consent by Dr A Patel (GDC 123456). Forms recorded before this rule keep the signer they were recorded with. A signer who has since been erased reads Signed by Erased patient (Parent).

Review

A dentist, hygienist or therapist clicks Review on the status line or on a submission awaiting review. The answers are shown, then every answer that proposes a medication, allergy or condition — a Yes, or something the patient wrote — needs a decision of its own. Beside each one is the fact on the patient's history it looks like (Looks like: Penicillin), found by its name. It is only a suggestion: nothing is chosen for you.

Each provisional alert this form raised needs Confirm or Archive, and archiving needs a reason. Record review waits until every answer and every alert has its decision. A review is saved whole or not at all: if one decision is refused — for example a correction of a fact a colleague has just replaced — nothing is saved, and you can review again.

A No never removes an allergy, medication or condition the history already holds: only a correction you choose replaces a fact.

Choose the outcome:

If the patient's history could not be loaded, the dialog says so and only a rejection can be recorded.

The review is recorded under the clinician's registration and cannot be changed; a second review is a new row.

Forms the patient fills in themselves, from a link or QR code, arrive through the same review. They always wait for it, whatever the form's review setting.

The Appointments tab

The record's Appointments tab has four sections, in the order the desk works them:

1. To book — the patient's unbooked treatment plan visits and their recalls (below). A plan visit that is ready shows Book, which opens the Diary to book that visit, with its length and the first day its gap after the visit before allows.
2. Upcoming — appointments still to come, each with its status as a coloured label. Move opens the Diary to move that appointment: click its new time and save. Cancel… asks for the cancellation reason before it cancels. Book above the list opens the Diary for the patient, and Later looks further ahead.
3. Waitlist — what the patient is waiting for; see the waitlist.
4. Past — folded away behind its count, for example Past (24), with the tally beside it: how many visits were Done, how many were a No-show, how many were Cancelled, and how early or late the patient usually arrives. Click it to open the list; Earlier reads further back. The counts are of what has been loaded, and say so. A cancelled appointment is listed here whatever its date.

Once a Book or a Move is saved, the Diary's confirmation offers to take you back to this tab.

Recalls

Recall types and their intervals are configured under Settings → Clinical catalogue → Recall types; the practice starts with Examination and Hygiene every 6 months and Periodontal review every 3 months, and completing a code that names one schedules it (or records the completion on the recall already open). A patient has at most one recall per type. On the clinical record they sit under To book on the Appointments tab, one row per recall: the due date (red once it has passed), the type and interval, its status as a coloured label — Active, Due, Overdue, Booked or Paused — the last time it was done, and the buttons:

• Book opens the Diary with the patient already chosen, ready to book the recall: click a free time, or click Find a time in the banner and the diary looks for free times that fit. It shows on an active recall that is not booked yet, whether or not it is due, so the next one can be booked ahead. The recall is booked together with the appointment: once it is saved, the recall's history shows it as booked, it leaves the recalls due in To do, and the confirmation offers to take you back to the record. A recall is booked by one appointment at a time, and only while that appointment stands: if it is cancelled or missed, however that happens, the recall reads as unbooked again and returns to the recalls due.
• Log contact records a call or message about it: Contacted or Missed. A missed call leaves a booked recall booked.
• Pause stops the recall being chased (with a reason); Resume puts it back.
• More holds Reschedule, Completed and Change interval; completing moves the due date forward by the interval unless you set the next date. A completion recorded here happened at the patient's site; for a patient with no site at a practice with several, Completed asks for the Location first.
• Schedule recall above the list creates one, due after the type's interval unless you set a date. Choose its Clinician — the list shows the active practitioners who work at the chosen site — and add a Note if you like; both are optional.

Change interval sets how many months the recall waits between visits. Left as it is, the current due date stays and only the visits after it use the new interval. Tick Recalculate the current due date (it starts unticked) to move it now: to the last time the recall was completed — or, if it never was, the day it was created — plus the new interval, and never earlier than today. The change shows in the recall's history as Interval changed.

A recall counts from the day the treatment was done, not the day it was entered: completing a recall's code on the chart dates the completion with the treatment's date. A treatment entered late and dated before the patient's latest completion of that recall is kept in the recall's history, but it never moves the due date, the booking, the site or a pause.

Every change is an event in the recall's history, shown under the recall's name. The due recalls also appear in the To do worklists, where Print letters posts a recall letter to every patient on the list.

With recall reminders switched on, patients are messaged before and after their due date until they book, each message with a one-tap link to book the visit, and each recall row shows Automatic reminders — how many were sent, the last one and the next. A visit booked for the patient, however it was booked, pauses them.

A recall counts as booked while the visit it was booked with is still to come. Once that visit has happened without the recall being completed — the visit was charted without the recall's code — the recall is due again and can be booked again.

A recall belongs to a site: the one it was scheduled at, then wherever it is next booked or completed — so a patient who moves from one of your sites to another takes their recall with them, and it is due on that site's list. A completion recorded on the recall itself is dated with the day at the site where it happened, in that site's own time zone, and the next due date counts from that day.