Read and update medical histories and conditions, use online medical history forms and questionnaires, and record GDPR and treatment consent properly.
Who it is for: practice managers and administrators, clinicians, dental nurses, receptionists.
In this guide:
- Read a patient’s medical history before treatment
- Record, edit and remove a medical condition
- Complete a medical history form with the patient
- Add online medical history form answers to the record
- Track pre-appointment questionnaires
- Record a patient’s GDPR consent
- Collect and manage signed consent forms
1. Read a patient’s medical history before treatment
You can find the patient’s conditions and their latest medical history form, and tell when it was last updated.
Why this matters. The GDC expects the dental team to take and update a medical history before every course of treatment, and many practices check it at every visit. Medications such as anticoagulants or bisphosphonates, allergies, diabetes, pregnancy or a pacemaker can all change what is safe. An out-of-date history is a common finding in complaints and CQC inspections.
Where to find it. Open a patient record and choose the Med. History tab.
How to
- The left panel, Conditions, lists the patient’s active medical conditions with Added On and Condition. Select one to see Details (Name, Severity, Description, Action (if any required)) and the Patient Note (Date Made, Made By and the note).
- The Medical Histories panel lists every medical history form completed, newest first, with Added On.
- Select a form to see its answers under Medical History: each Question with Yes, No and any Comment. Section headings are shown in bold.
- Check the Added On date of the newest form. If it predates this course of treatment, ask the patient to complete a new one (at the desk, on the tablet or online).
Good to know
- Forms completed on the tablet or online carry the patient’s signature.
- Conditions with a severity of warning or hazard deserve a pop-up note too, so nobody misses them.
- The medical history can also be shown inside the appointment editor if your practice has turned on Show Medical History in Appointment in Preferences.
More detail: Patient medical history.
2. Record, edit and remove a medical condition
You can add a condition from the practice list, and know who may edit or delete one.
Why this matters. The Conditions list is the at-a-glance summary of what matters medically: “warfarin”, “penicillin allergy”, “type 1 diabetes”. Keeping it accurate means the dentist doesn’t have to read the whole form every time.
Where to find it. Med. History tab, the + button beside Conditions (tooltip Add Patient Medical Condition).
How to
- Click Add Patient Medical Condition.
- In the dialog, type in Search to filter the practice’s list of conditions and select the one you want.
- Add a Note if it helps (for example “INR checked 3 days before extractions”).
- Click OK. The condition appears in the Conditions list.
- To change it, right-click the condition and choose Edit Condition (opens Edit Patient Medical Condition).
- To remove it, right-click and choose Delete Condition, then confirm Are you sure you want to delete this patient medical condition?
Good to know
- Edit Condition needs the edit patient medical condition permission (AID_EDIT_PATIENT_MEDCON). Delete Condition needs AID_DEL_PATIENT_MEDCON. If you don’t see them, you don’t have those permissions.
- Print Condition is in the menu but not yet working.
- The list of conditions, and their severity and suggested action, is set up by an administrator in Housekeeping › Medical Conditions.
- Prefer marking a resolved condition in a new medical history over deleting it, so the record shows what was known and when.
More detail: Patient medical history.
3. Complete a medical history form with the patient
You can record a new medical history form in ChiralCloud, and edit, delete or print one if permitted.
Why this matters. When a patient fills in a paper form, or answers questions in the surgery, the answers need to go into the record so they are dated, searchable and printable. A new form for each course of treatment gives an auditable trail.
Where to find it. Med. History tab, the + button beside Medical Histories (tooltip Add Patient Medical History).
How to
- Click Add Patient Medical History. The Add Medical History dialog shows each question as a card.
- For each question choose Yes or No. Add details in the comment box where the answer is Yes (for example the drug name and dose).
- Click OK to save. The new form appears at the top of Medical Histories.
- Right-click a form to:
– Edit Medical History (needs AID_EDIT_PATIENT_MHF),
– Delete Medical History (needs AID_DEL_PATIENT_MHF, confirm Are you sure you want to delete this patient medical history?),
– Print Medical History to print or save as PDF.
Good to know
- A form you enter on the patient’s behalf has no patient signature. Where you can, ask the patient to complete it themselves on the tablet or online so they sign it.
- The questions come from Housekeeping › Medical Conditions (conditions marked to appear on the medical history form, in their set order).
- Don’t edit an old form to bring it up to date: add a new one, so the history shows what the patient said at each point.
More detail: Patient medical history.
4. Add online medical history form answers to the record
You can send a patient an online medical history form and import their answers into the medical history.
Why this matters. Asking patients to complete their medical history online before they come in saves time in the surgery and gives the clinician a signed, current form to review in advance. This is the series of three videos linked to this step.
Where to find it. Send: the patient toolbar Send this patient an Email, or Mail Shots › Patient Forms for many patients. Review: Patients › Mail Shots › Patient Forms, right-click the form and choose Show Patient Responses, or the patient’s Patient Forms tab.
How to
- Open the patient and click Send this patient an Email.
- Set Email type to Patient Form Email and pick your published medical history form. The send button reads Send (Patient Form Email). Click it.
- When the patient submits, open Show Patient Responses for the form (or the patient’s Patient Forms tab) and select the response.
- Click Add to medical history. The dialog lists every question with the patient’s answer. Each Yes has Add as active condition, already ticked for warning and hazard conditions.
- Check the list and click Add to medical history. You’ll see Added to … medical history (n active conditions added) and the form appears on Med. History with the patient’s signature.
Good to know
- If the form arrived without a patient (for example a new patient), you are asked to Choose the patient this form belongs to first.
- Each response can only be added once: This form has already been added to the medical history.
- A GDPR consent box on the same form isn’t a medical answer. It updates the patient’s GDPR consent tick instead.
More detail: Online medical history forms.
5. Track pre-appointment questionnaires
You can find incomplete, pre-completed and completed questionnaires and complete one on the patient’s behalf.
Why this matters. Some practices ask patients a short screening questionnaire before each appointment (for example infection screening, with oxygen saturation and temperature taken on arrival). These lists show who still owes you an answer and give you evidence that screening was done.
Where to find it. Compliance › Questionnaires, then Incomplete(s), Pre-completed(s) or Completed(s).
How to
- Incomplete Questionnaire(s) lists patients sent a questionnaire who have not answered (Patient, Added On Date). Right-click and choose Complete Questionnaire to fill it in with the patient, for example over the phone.
- Pre-completed Questionnaire(s) lists questionnaires answered before the appointment (Pre-Appointment Date, Completed By Practice or Patient). Right-click for Show Questionnaire or Print Questionnaire.
- Completed Questionnaire(s) lists questionnaires confirmed on arrival (Upon Arrival Date). Right-click for Show Questionnaire or Print Questionnaire.
- On any list, Patient Details (right-click, or double-click the row) opens the patient’s record.
- In the questionnaire screen, answer every question Yes or No, record measurements such as Enter Patient Sp02 and Enter Patient Temperature oC on arrival, then Save Questionnaire and confirm. Print Questionnaire prints it.
Good to know
- You can also send a questionnaire to the waiting-room tablet from Find Patients › Compliance › Questionnaire.
- Every question must be answered: you’ll see Please answer all the questions either Yes / No otherwise.
6. Record a patient’s GDPR consent
You understand what GDPR consent controls in ChiralCloud and how it is given, recorded and withdrawn.
Why this matters. You don’t need consent to hold dental records: UK GDPR allows it for providing health care. But marketing-style messages, newsletters and many mail shots rely on consent, and patients have the right to withdraw it at any time. ChiralCloud records this as one tick, GDPR consent given, and respects it automatically. This step has a three-part video series.
Where to find it. Patient side: the patient portal asks for it (Sign GDPR Consent Form). Staff side: the patient’s Check Lists tab, built-in GDPR list.
How to
- When a patient logs into the portal without consent recorded, they are asked to Please Complete the GDPR consent form before continuing. They read the form, choose Patient Gives Consent or Patient Does Not Give Consent, sign and click Register Your Consent, then confirm.
- Their answer ticks or unticks GDPR consent given on the Check Lists tab, shown as “Patient portal”.
- If a patient tells you in person or by phone that they withdraw consent, open Check Lists, select the GDPR list and untick GDPR consent given. The status shows Not given.
- A GDPR box on any Form Designer form also updates the tick when the response is linked to the patient.
Good to know
- Every patient starts ticked (“Ticked by default”) until they say otherwise.
- Unticked patients are left out of every Email, SMS and Patient Forms mail shot. You’ll see Patients who haven’t given GDPR consent are left out of mail shots. on the mail shot screen.
- Appointment reminders and recalls are part of care and are not affected.
- Record withdrawals the same day. Sending marketing after withdrawal is a breach.
More detail: Gdpr consent.
7. Collect and manage signed consent forms
You can send consent forms to the tablet, and print, email or edit signed consent documents.
Why this matters. Since Montgomery v Lanarkshire (2015), valid consent means the patient understood the material risks, the reasonable alternatives (including doing nothing) and the costs, and had time to decide. A signed form is not consent on its own, but it is good evidence that the discussion happened. Keep the clinical conversation in the notes as well.
Where to find it. Send to the tablet: Find Patients, right-click the patient, Compliance › Consent Forms. Signed forms: patient record Documents tab, Consent Forms section.
How to
- In Find Patients, right-click the patient and choose Compliance › Consent Forms.
- In Consent Forms, tick the forms needed (Consent For, Required) and click OK. They wait on the waiting-room tablet for the patient.
- The patient opens Consent Forms on the tablet, reads, signs, clicks Save This Signature and confirms Are you sure you want to save these consent form(s). (Patients can also sign from the portal via Sign Consent Forms.)
- The signed document appears on the Documents tab under Consent Forms. Right-click it for Print Consent Document, Email Consent Document or Edit Consent Document.
Good to know
- Give the patient a copy of anything they sign. Email Consent Document shows an Email Preview before it goes.
- Treatment plans and payment plans can also be signed on the tablet (Sign Treatment Plans, Sign Payment Plans).
More detail: Patient documents.