If you don’t record discussions with patients and warnings in the records, how can you hope to defend against a claim for negligence?
A clinician examined a patient who asked whether something could be done to replace his upper right second premolar tooth. The patient had browsed through the literature in the waiting room about implants and bridgework and discussed the various options with the dentist.
Indeed the dentist recalled fully discussing the concept of an implant-retained prosthesis and the cost for such a procedure. He also advised his patient that a three-unit bridge using both the upper first molar and premolar as abutments was another alternative. The patient decided to go ahead with the bridgework because it would be quicker and less expensive.
The dentist made a three-unit bridge as agreed but unfortunately the patient found it difficult to tolerate because he was getting food caught underneath it. By mutual agreement the bridge was removed, before making a crown and a porcelain inlay to restore the distal and mesial abutments respectively.
The dentist carried out some further preparation on the molar tooth and fitted the crown at the following visit. Unfortunately the patient experienced pain from the crowned tooth, which subsequently had to be root-treated.
The patient instructed a lawyer to make a claim in negligence against the dentist alleging that he had not warned of the risks of preparing the tooth for a coronal restoration, nor had he fully explained the advantages of having the space restored with an implant.
Although the dentist recalled discussing the various options and material risks with the patient, there was unfortunately nothing entered in the records to support his claim that the consent process had been carefully completed.
In view of the lack of supportive records, it was decided it would be difficult to defend the claim and a settlement was effected to compensate the patient for the destruction of the abutment teeth and the costs involved for further restorations of these teeth in the future.
Unless conversations and warnings are recorded contemporaneously in the notes, they may well be deemed not to have occurred if a problem subsequently arises.