Defending against a claim of negligence stands a much greater chance of success if your records are straight...
A medical history often dictates the action to be taken to supplement treatment in order to ensure its success. In many cases, careful details of actual treatment recorded on the record card can counter allegations that the overall care of the patient was inappropriate.
A patient presented with a history of ‘hole in the heart’ and the need for antibiotic cover. She required extensive restorative treatment including root canal therapy and at all times, treatment was carried out under antibiotic cover.
At one particular appointment, seven small restorations were inserted in the upper right quadrant (anterior and posterior) and the lower left quadrant running from 31 to 37. The supply of local anaesthesia required a number of infiltrations and an inferior dental nerve block. A note was made on the record card that 3x2.2ml cartridges of lignocaine were used.
Subsequently seen in hospital, the patient was diagnosed as ‘suffering from the side-effects of a large amount of lignocaine’ and she subsequently sued for negligence. The initial allegation was that she had overdosed on the anaesthetic because she suffered from a hole in the heart condition.
The careful recording of both the medical history and the treatment provided ensured that the claim could be successfully defended.