What may seem a run-of-the-mill appointment for the dentist can often be a major event for the patient. Keeping detailed records of discussions and warnings is essential.
A classic example of a failure to communicate often arises over the extraction of third molars. Patients, judges in civil claims and dental councils often use the argument that to attend the dentist for the removal of a third molar is a significant ‘life event’ for a patient. The patient will often be able to recall every detail including explanations (or lack of them) given by a dentist as well as details of the dentist’s mood or attitude.
To the dentist, the patient is just one of many whose third molars are being removed. In order to ensure the dentist can later discuss the details of the care of a particular patient, it is important that the record documents the history of any symptoms, the clinical findings along with any investigations and tests that were performed.
The notes should demonstrate the justification for the treatment including the choices given to the patient In addition a clear note should be made of the warnings about the risks and consequences of the procedure and the post-operative instructions given. A detailed note of the procedure and any difficulties encountered in the procedure should also be kept, together with the action taken.
Memory is not enough
A patient attended for an extraction under sedation. There was a discussion about which tooth to remove, but the patient’s abiding memory was that no discussion had taken place about the risks and post-operative consequences and that no warnings had been given about the likelihood of such a significant outcome. Nothing was written in the records about the consent process for the surgical procedure. The dentist suggested that it was his normal practice to warn about the risk of nerve damage but he could not recall the particular patient or prove that he warned them of the possible consequences.
The patient suffered permanent nerve damage and subsequently sued both for a failure to warn and the avoidable damage caused to the nerve.
Good communication must go hand in hand with good record keeping.