Referral and Negligent Referral in a Dental Practice

A dental professional’s failure to refer patients that require care outside the practitioner’s background, experience, or training can lead to malpractice claims. This case discussion covers risk management issues involving allegations of negligence, failure to diagnose, and failure to refer. We also provide actionable strategies to help dental professionals keep patients safe and avoid potential liability issues when referring patients to specialty practitioners.

During a routine prophylaxis visit, a middle-aged patient reported a tongue mass, which the general dentist evaluated as an aphthous ulcer (benign and noncontagious). Several months later, another practitioner biopsied the mass and diagnosed Stage IV squamous cell carcinoma. Surgery and radiation treatment were undertaken, and plastic surgery was required. The patient alleged dental negligence, failure to diagnose, and failure to refer to a specialist. The defendant dentist claimed that he had told the patient to follow up with a primary care physician (PCP) or an oral surgeon.

Risk Management Discussion

The dental record contained no documentation of a formal referral to a PCP or specialist, and the dentist did not document his observations or referral recommendation. The adverse result in this case may have been avoided—or the impact lessened—if the dentist had (1) documented his evaluation and testing to demonstrate a low suspicion of cancer or (2) recorded details of a referral with follow-up on the referral.

The following strategies can help dental professionals keep patients safe and mitigate risks:

• Provide treatment only within the scope of your expertise. Treating patients for conditions that are outside your training and experience can increase the risk of patient harm. If the patient is harmed, you will be held to the standard of care for that specialty.
• Explain why the referral is needed for a particular treatment or condition and that you will remain the patient’s general dentist. Let the patient know what to expect from the specialist and treatment, and reassure the patient that you will stay in contact with everyone to ensure the best possible outcome. Effective communication is critical to a successful referral and to shared decision making.
• Provide the patient with a formal referral slip or prescription that notes the timing and reason for the referral.
• Help the patient find the best specialist. If possible, provide options, and involve the patient in shared decision making in selecting the specialist. Because a dental professional can be held liable for referring a patient to a specialist who is not competent to perform the treatment, it is important to refer patients to specialists you have independently assessed.
• Schedule the specialist appointment while the patient is still in your office. Even if the patient later reschedules or cancels the appointment, you and your staff have facilitated the referral.
• Avoid miscommunication with the specialist by providing a formal written referral. Always document the details of phone referrals followed by a written referral to the specialist after the call. Retain the same information in your records.
• Include the following information in referral letters:
• Patient identification and demographics.
• Diagnosis and prognosis, including why and when the referral should occur.
• Date of the referral and last date the referral may take place.
• Evaluation and treatment completed to date.
• Copies of diagnostics performed, including information about when it was collected.
• Desired evaluation or care the specialist is requested to complete.
• Your plan for after-care following the specialist’s intervention.
• A request for a consultation report and ongoing status reports.
• Track patient referrals and return visits using a centralized, uniform tracking process that is separate from the patient’s record. The tracking system should provide reminders or tasks to move the process along or allow documentation about its lack of progression. The tracking should cover the timeframe from the patient’s referral to the return visit to the general dentist. To avoid missed follow-up attempts, have your staff make the patient’s return appointment at the time the specialist appointment is made. If the referral is not completed in a timely manner, the process should include contacting the patient and specialist to facilitate care.
• Document the referral process, including evaluation, treatment, and discussions with the patient. In the event of a claim, documentation is the best evidence. Keep copies of written communications in the patient record along with evidence of verbal communications (including phone messages with both the patient and specialist).
• Document patient nonadherent/noncompliant behavior. A well-documented record shows evidence of your efforts. Emphasize to the patient that failing to follow treatment or referral recommendations may result in an adverse outcome, disability, or even death (if applicable). (See our articles, “Nonadherent and Noncompliant Patients: Overcoming Barriers” and “Noncompliant Patients Increase Liability Risks for Practitioners.”)
• If the patient refuses specialty care, document the informed refusal, including the patient’s involvement and the counseling you provided. (For more information, see our article “Informed Refusal” and our sample form “Refusal to Consent to Treatment, Medication, or Testing.”)
• If, after thorough counseling, the patient continues to refuse your recommendations, you may need to consider ending the relationship. Carefully document the events leading to the decision to withdraw care. (For more information, see our article “Terminating Patient Relationships” and our resource “Quick Check: Patient Dismissal Process.”)

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.