Every dental professional is responsible for their client’s chart as it is a legal representation of dental services provided.1 Documenting all procedures, client communication and clinical findings ensure the clinician accountability to the government, insurance company and client.1 Additionally, effective documentation can protect the clinician if the chart is called upon as evidence during a legal dispute.1
The importance of documentation was reinforced during a clinical session when a client that presented with numerous dental complications refused to receive local anaesthetic (LA) on numerous occasions. After many attempts to help her understand the benefits and few risks of LA, she insisted that I proceed with scaling without LA. Respecting her wishes, I proceeded to document the discussion with my client – first, to protect myself should a dispute occur; second, to ensure future clinicians are informed of this situation. The client was referred to the DMD program; however, she had a history of refusing treatment when she was contacted and was permanently banned from the program. During her recall appointment, she was upset that she had not received a call from a DMD and insisted on speaking with the clinical coordinator. After a long discussion involving the clinical coordinator and a look through the communication history, it was clear that the client had been deferring dental treatment due to fear of needles. Although the client claimed that she had not been contacted and that such events did not occur, it was documented in the system. Due to the unreliability of the client, we could not initiate another referral to the DMD program and had to dismiss the client from the DHDP program due the risk of possible allegations of supervised neglect.
Supervised neglect is defined as a case in which a “regularly examined patient shows signs of a disease or condition but is not informed of its presence or progress”. In our case, although we informed the client about her disease status and the importance of receiving treatment, she consistently refused treatment and would deny that the clinic’s attempt to contact her for dental treatment. This experience helped me truly appreciate the detailed documentation that we are taught throughout our clinical experience. Although documentation can be time consuming and tedious, documentation of client procedures, communication and clinical findings will prevail, especially in situations where the client is making allegations against the clinic or clinician.
- Charangowda BK. Dental Records: An Overview. J Forensic Dent Sci. 2010 Jan-Jun; 2(1): 5–10. doi: 10.4103/0974-2948.71050
- CHDA. Dental Hygiene: Definition, Scope, and Practice Standard. 2002.