When patients contradict what they documented in their medical history

March 17, 2025

Have you ever had a patient who tells you something different than what’s on their medical history? Who wins? Verbal or written documentation? Join us to learn this and more in Medical History Mysteries.

Pamela Maragliano-Muniz, DMD

Tom Viola, RPh, CCP

What do we do when a patient tells us something different than what they documented on their medical history? For example, I have a patient who disclosed in their medical history that they have an allergy to penicillin. Then they called me and asked for a prescription for amoxicillin because they had pain in their mouth.

Who wins? Verbal or written documentation?

Join us in this episode of Medical History Mysteries as we talk about protocols to follow in this type of situation.

Thumbnail image credits Kobus Louw / iStock / Getty Images Plus

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Editor’s note: This article first appeared in Clinical Insights newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe.

About the Author

Pamela Maragliano-Muniz, DMD

Pamela Maragliano-Muniz, DMD, is the chief editor of DentistryIQ and editorial co-director of Through the Loupes. Based in Salem, Massachusetts, Dr. Maragliano-Muniz began her clinical career as a dental hygienist. She went on to attend Tufts University School of Dental Medicine, where she earned her doctorate in dental medicine. She then attended the University of California, Los Angeles, School of Dental Medicine, where she became board-certified in prosthodontics. Dr. Maragliano-Muniz owns a private practice, Salem Dental Arts, and lectures on a variety of clinical topics. You may contact her at [email protected].

About the Author

Tom Viola, RPh, CCP

With more than 30 years’ experience as a board-certified pharmacist, clinical educator, professional speaker, and published author, Tom Viola, RPh, CCP, has earned the reputation as the go-to specialist for making pharmacology practical and useful for dental teams. He is the founder of Pharmacology Declassified and is a member of the faculty of more than 10 dental professional degree programs. Viola has contributed to several professional journals and pharmacology textbooks, and currently serves as a consultant to the American Dental Association’s Council on Scientific Affairs.