When a patient comes to the point of making a complaint, without adequate records to prove your professionalism you could find yourself lacking a solid defence. This case study illustrates how such a situation might arise...
A dentist received a written complaint from a long-standing patient who alleged he had failed to adequately treat her periodontal condition. The patient had first attended some 10 years previously with advanced periodontal disease and this had been recognised by the dentist during his initial examination.
A panoral film taken at the time clearly showed the extent of the severe bone loss throughout the patient’s mouth and this was adequately charted in her dental records with details of both short and long-term treatment plans. The patient was fully informed of the situation, shown the radiographs and agreed to undergo extensive periodontal therapy. She was also counselled to attend every three months for examinations, scaling and oral hygiene instruction. The dentist monitored the patient’s condition over the years and her periodontal status improved.
Although the dentist saw the patient regularly and carried out the appropriate care and treatment, after some eight years her periodontal condition began to break down, causing mobility of a number of anterior teeth. The patient was naturally alarmed over this and the dentist advised her she was having an acute exacerbation of her pre-existing periodontal condition and suggested a referral for specialist advice at the nearby dental hospital.
The patient was examined by a consultant periodontist who, without having full details of the patient’s past dental history, commented somewhat inappropriately that something could have been done to save a number of these teeth if the treatment had been instituted at an earlier stage. The patient was naturally aggrieved and made a complaint to the dentist, who sensibly contacted Dental Protection for advice.
A dento-legal adviser helped the dentist compose a letter for the dentist to send to the patient. This advised her that on her first attendance at the practice her periodontal condition was compromised and that the current radiographic evidence did not show any major deterioration since the initial consultation. The letter also explained that periodontal disease manifests itself by years of quiescence and occasional bouts of sporadic activity, and that is why it was felt necessary to refer her for a second opinion.
The patient unfortunately did not accept the dentist’s reasoning. She subsequently made a complaint through her lawyer to the national regulatory body, which asked our member for his written observations.
Dental Protection was happy to offer further assistance and worked with the dentist to make a submission to the regulatory body. The regulatory body accepted that the dentist had acted perfectly appropriately. The dentist heard nothing further from the patient, who was obviously advised that it would be futile to pursue any further action against him.
How can records let us down?
Dentists who do not keep adequate records are placed in an invidious position when a patient makes a claim about some aspect of care which has been provided and of which the dentist has little recollection. A prime example is when a patient changes dentist and is told that he or she requires extensive treatment, usually at significant cost.
Naturally any patient would be concerned and feel antipathy towards a previous dentist where additional treatment is required. If the previous dentist has not kept records of the patient’s condition when last attending or notes of refusal to undergo treatment recommended, then defending allegations against the dentist could prove difficult. It would be very much the dentist’s word against that of the patient. Adequate records ensure that details of treatments and discussions are properly maintained.