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Cut and dried? Patient follow-up matters

16 June 2021

Many practitioners struggle with the issue of patient follow-up. Is it our responsibility, or that of the patient, to ensure recall or follow-up visits are attended? Or is it a bit of both? Dr Simrit Ryatt, Dentolegal Consultant for Dental Protection, provides advice and guidance 

The questions above are often raised and it can be difficult to know what to do in any given situation. Broadly, we recommend revisiting the general legal and ethical principles behind our responsibilities towards our patients. Your Dental Council's ethical and professional conduct guidance is helpful in this, and when combined with a review of what our medical colleagues would typically do in similar situations, we can better understand our obligations and best practice.

Do I have a responsibility to my patient to ensure attendance at recalls?

Generally speaking, dentists have an obligation to ensure that patients receive further medical advice on matters of clinical significance, where clinical significance is based upon both the probability that the patient will be harmed if further medical advice is not obtained and the likely seriousness of the harm if it were to arise. 

We know from our own clinical experience that most orthodontic patients require recall at least every six months by their GDP, irrespective of the frequency of orthodontist visits, as nearly all orthodontists provide written advice to patients stating this. That’s because there’s a greater risk of caries and periodontal disease in patients with orthodontic banding than those without. 

If we accept this as good practice, then it would seem that any responsibility on our part largely depends on our patient and the stability of their oral health, as well as the likelihood that problems may develop or pre-existing conditions deteriorate in the absence of appropriate recalls. This means that a patient with a history of poor oral hygiene, unstable periodontal disease or a high caries rate needs to attend regularly for recalls, while another without these risk factors may not. 

Our clinical records should clearly identify the patient at risk and indicate they were informed of the significant risks associated with their presenting condition and the implications of both treatment and no treatment to the likely outcome of their oral health. Documenting a diagnosis without also noting the discussion around that diagnosis, may not form an adequate defence, as there may not be sufficient evidence of the patient having been informed of the risks associated with their condition and treatment needs.

On that basis, we have a duty to ensure (to a reasonable degree) that at-risk patients attend for follow-up, if there is a reasonable risk of harm should they fail to do so.

How do I follow them up? They don’t answer their phone or confirm their attendance 

When a patient is not responding, it is quite possible they are seeking ongoing care at another practice. Alternatively, they may not be, and patients have every right to refuse treatment. “We can take a horse to water, but we can’t make it drink”, so our responsibility to our patients only goes so far. 

We must balance our need to follow up our patients with their right to exercise autonomy in decisions about their health. Our dilemma is knowing if our patients are intentionally exercising their right to refuse treatment.

It is reasonable to send a patient a recall letter, email or SMS as a reminder of an imminent recall. If that first contact is ignored, a second contact, perhaps a call from the practice, is appropriate, just in case the first reminder was accidentally overlooked or forgotten. 

A further letter is justified for those patients who are at risk, elaborating in layman’s terms why it is important for the patient to attend. For all others, it can be argued that reasonable attempts have already been made to follow up the patient, to no avail. 

Naturally, any patient with a history of being ‘difficult’ or with a poor attendance history may need further reminders. 

Where patients have been referred for specialist care and have not followed up with an appointment, a short note to remind the patient of the reason for the referral and the risks of no treatment may be prudent.   

What else can I do?

Documentation is key. In the same way that we always recommend that practitioners document both treatments undertaken and the reasons for ‘no treatment’, it is advisable to record all occasions of contact with patients in the clinical record. Reminders should be logged as having been sent. Copies of correspondence to patients should also be kept. Always log non-attendance in the clinical record, as such logs have formed an invaluable defence to later allegations of lack of appropriate care. 

What about the walk-in for whom I performed an endodontic dressing? Will I be held accountable if they don’t follow up with definitive root canal therapy?

Again, the onus is on us at the time of treatment to adequately document the reasons for treatment and the risks and benefits of different treatment options, including the risks of no treatment. Your notes in such a case should outline that the patient was informed of the need for further root therapy appointments and that a failure to do so might result in pain, swelling or other similar symptoms, or the eventual loss of the tooth. 

A failure to document such information could leave a clinician vulnerable to allegations of failing to inform the patient of the need for further treatment.

It has proved a helpful defence to have evidence of a referral having been written and sent, as this definitively demonstrates that follow-up was organised for a patient.  This applies even for those patients who express uncertainty as to their interest in a timely follow-up. A copy of any referral should be sent to the patient as both a courtesy and to demonstrate that a communication about the need for further treatment has occurred. Consider showing this by making the patient a recipient of a ‘CC’ in the referral.  

So yes, we do have some responsibility, and we need to exercise this respectfully and document it appropriately.