What must be included in the first patient visit record in a dental hygienist's practice?

In the first patient visit record, it is crucial to include the medical history and any contraindications. This information provides the foundational context for the dental hygienist to understand the patient's overall health and any conditions that could affect treatment. A comprehensive medical history helps identify past illnesses, allergies, medications, and any specific health conditions that might pose risks during dental procedures. Knowing contraindications is also vital to ensure safety and avoid adverse reactions.

While a treatment plan is important, it typically develops after the initial evaluation and review of the patient's medical history. Referral information can be relevant in certain situations but is not a standard component of the initial visit record. Insurance details may be necessary for billing purposes but do not directly impact patient safety or the provision of care at the first visit. Thus, the most critical documentation for establishing a baseline for treatment and ensuring patient safety is the medical history and contraindications.