Case Study: Documentation and Scope of Practice Issues

By David O. Hester, FASHRM, CPHRM, Director, Department of Patient Safety and Risk Management

Obtaining written and verbal informed consent and patient response to follow-up care are crucial steps to improve patient safety and mitigate risk in your practice.

The patient, a 52-year-old female, contacted her dentist and stated that she had two broken teeth. Upon examination, the dentist recommended the removal of what remained of the broken teeth. The surgery was performed the next day to remove the teeth. The patient was discharged in good condition. The dentist did not have the patient sign an informed consent form prior to the procedure. The dentist later testified that he explained possible complications to the patient. However, the dental record did not include documentation confirming the verbal informed consent discussion. The day after being discharged, the patient called the dentist’s office and reported extreme pain at the surgical site. She requested to speak with the dentist but was told that the dentist was unavailable. She asked for an appointment, but was informed that the earliest appointment would be in five days.

The receptionist did not document the phone call and the patient testified that she was instructed by the receptionist to “just take some Tylenol.” The patient sought treatment from a second dentist. An examination by the second dentist determined that root tips had been left in place during the procedure and deep infection had occurred at the surgical site. The patient required further surgery and antibiotics to fully recover.

The patient pursued a claim against her original dentist.

Risk Management Discussion
An allegation of improper performance of a procedure is a common source of dental claims. The original dentist did not obtain a signed informed consent form. In addition, the dental record did not note that possible complications from the surgery were discussed with the patient. In this case, the original dentist did not remove all of the root tips, which caused pain and the need for additional surgery by a second dentist. The case was further complicated by the lack of policies and protocols to ensure all office staff follow guidelines within their scope of practice and job responsibilities. Guidelines are crucial to correctly triage inquiries to the appropriate staff member and/or the dentist for a timely response to the patient.

The following steps can help you improve quality and mitigate risk:

  • Explain the proposed treatment, expected results and potential complications to the patient. Have the patients explain what he or she expects from the proposed treatment.
  • Document all verbal discussions regarding the treatment plan in the dental record, including confirmation that the patient provided verbal understanding.
  • Develop policies and protocols that guide staff to ensure the timely follow-up of patient inquiries.
  • Ensure that all staff members document in the dental record telephone calls received from patients.
  • Educated all staff members and develop policies that ensure they do not practice outside of their license, expertise or scope of practice.

The guidelines suggested here are not rules, do not constitute legal advice and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Reprinted with permission. ©2016 The Doctors Company. For more patient safety articles and practice tips, visit


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