Tuesday, November 01, 1994
by Richard D. Weber, J.D.
MDA Legal Counsel
Published in the November/December 1994 issue of the Journal
Question: I know I am supposed to document all treatment rendered to a patient, but is it also necessary to document other patient contact, such as telephone calls canceling or rescheduling appointments?
Answer: All information arising out of the doctor-patient relationship should be recorded in the patient's file. This includes canceled or rescheduled appointments. Patients who fail to keep their appointments are at a higher risk for poor outcomes. Recording the information would allow the dentists and staff to be conscious of patients who frequently miss appointments. Reminders could be sent to the patient.
Moreover, documentation would provide evidence regarding the patient's noncompliance with treatment, which could aid in the defense of a malpractice case. No-shows and cancellations occurring on the day of the appointment can easily be recorded on the chart, which should be readily available. Cancellations or rescheduled appointments in advance of the appointment date should also be recorded.
This is often overlooked and sometimes viewed as inconvenient and unnecessary. The dental office should adopt some efficient method of accomplishing this task, such as adhesive-backed "cancellation stickers," which can be easily placed in the dental record at a later date and more convenient time. This documentation should be recorded contemporaneously, even though the actual filing can be delayed.
Question: My handwriting is horrendous. What are my options in making sure the patient records are legible? Must they be legible? Should I type the records or prepare a summary if the records are requested by the patient or the patient's attorney?
Answer: A dentist should do his or her best to make records legible, even if this requires the dentist to print information. Under no circumstances, however, should the dentist prepare any summary or otherwise type the records at a subsequent time. This is not necessary and could backfire in the legal context. If a patient directly requests records or a patient's attorney submits a duly executed authorization requesting the records, the dentist should furnish a copy of the raw records. A dictated summary could contain information not in the records and it may also appear self-serving or prove incriminating. In addition, the dentist has no obligation to assist the plaintiff's attorney in discovery by offering any explanation of the records.