Documentation and Scope of Practice Issues in Dentistry

Allegations of improper performance of a procedure are a common source of dental claims. In this case study, we analyze issues leading to a patient’s injuries—including the lack of documentation and staff protocols—and provide strategies to help dental professionals keep patients safe while improving quality and mitigating risk.

An adult patient contacted a dentist about two broken teeth. Upon examination, the dentist recommended removing the stumps and the roots of the broken teeth. The patient agreed, but the dentist did not obtain the patient’s signature on an informed consent form prior to the procedure. The dentist later testified that he had explained possible complications to the patient but had not included documentation in the dental record that confirmed the verbal informed consent discussion.

The next day, the dentist performed the surgery to remove the stumps and the roots, and the patient was discharged in good condition. The day after the procedure, the patient called the dentist’s office and reported extreme pain at the operative site. The patient asked to speak with the dentist but was told that the dentist was unavailable. The patient then requested an appointment but was informed that the earliest available appointment was in five days.

The receptionist did not document the phone call. The patient later testified that the receptionist’s instruction was 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 a deep infection had occurred at the operative site. The patient required further surgery and antibiotics to fully recover.

The patient pursued a claim against the original dentist.

Risk Management Discussion

The original dentist did not obtain a signed informed consent form, and the dental record did not reflect the dentist’s informed consent discussion with the patient about the procedure’s risks, benefits, alternatives, and potential complications.

In this case, the original dentist did not remove all the root tips, resulting in pain and the need for additional surgery by a second dentist. The case was further complicated by the lack of policies and protocols ensuring that all office staff were following guidelines within their scope of practice and job responsibilities for managing patient calls. Guidelines are crucial for correctly triaging inquiries to the appropriate individual to make sure that the patient receives a timely response.

The following strategies can help dental professionals improve quality and mitigate risk:

• Explain to the patient the proposed treatment, expected results, and potential complications. Ask what the patient expects from the proposed treatment.
• Document in the dental record all verbal discussions regarding the treatment plan and possible complications, including confirmation that the patient provided verbal understanding.
• Obtain written informed consent from the patient and place the signed consent form in the dental record. (See our article “Informed Consent: Substance and Signature” and find a sample Dental Procedure Informed Consent form on our Informed Consent Sample Forms)
• Develop policies and protocols that guide staff and ensure that patients receive timely follow-up to their inquiries. Provide staff training on questions to ask the caller and when to refer a call immediately to the dentist. (See our article “Telephone Communication for Healthcare Providers: Safety Strategies.”)
• Confirm that staff members document in the dental record all telephone calls received from patients. Documentation should include the date and time of the call, who received it, the nature of the conversation, how the call was managed, to whom the message was referred, and the follow-up plan. (See our article “The Faintest Ink: Documentation to Defend Quality Patient Care.”)
• Follow state requirements on education, training, credentials, and permitted functions for dental staff.
• Implement policies and provide education to make sure that staff members function within the scope of their license and expertise.

For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.