Risk Management Q&As

We recommend not responding. If you feel compelled to respond, write something like this: “By responding to this post, I am neither confirming nor denying that you are a patient of my practice. If you would like to discuss the issue, please call my office at _______________.”

If patients come in and mention the negative review, we recommend addressing it as follows: “Yes, I am aware of the review. Unfortunately, anyone can write a review about the practice online – whether they are a patient of mine or not. Being a healthcare provider, I cannot respond. But you are here today, so let’s get started.”

A patient must be notified in writing. TDIC does not recommend dismissing a patient who is mid-treatment, i.e. in a provisional or temporary. You have the option of giving the patient a reason for the dismissal, such as non-compliance if they are not complying with active treatment requirements or necessary appointments. Alternatively, you may choose to dismiss with no reason, if the doctor-patient relationship has a loss of trust.

Give the patient a reasonable amount of time to seek a new dentist. Often, 30 days from the date the letter was mailed is sufficient, during which time you agree to see them for emergencies only. You should provide valid referrals for the patient to find a new dentist, such as the local dental society, or refer them back to their insurance carrier, but do not provide specific names of other dentists.

TDIC has sample dismissal letters that can be customized by your practice for withdrawing from care for your patients. Please contact a risk management analyst directly for sample letters or if you are unsure about your liability in relation to the dismissal.

Check with your local dental board for state specifics regarding closing a practice. With that said, you should notify your patients of record with a letter advising them of the closure of the practice. The letter should indicate your actual termination date, where they can locate their records after that date, and the importance of continued dental care. In some instances, you may also place an ad in a local newspaper. Comply with your state’s requirements for retention of records timelines, and, if placing them in charge of a custodian, be sure to have it spelled out who will pay for storage and reproduction costs of records.

On the surface, arbitration appears to be a perfect solution for the dentist as well as the patient. It can be less expensive than litigation and typically moves expeditiously. However, arbitration does have its drawbacks.

First, having a patient sign an arbitration agreement binds you and the patient to abide by that agreement, even if the problem could be resolved in another manner. There is no option of appealing the decision.

Second, in arbitration only two to three arbitrators, as opposed to a 12-member jury panel of your peers, hear your case. Additionally, arbitrators who often hear similar cases may have preconceived notions regarding dentistry, which may affect how they evaluate your case.

Finally, consider the impact of asking your patients to sign such an agreement. Often patients view signing an agreement prior to treatment as a pre-admission of substandard care. Some will perceive it as your attempt to strip them of their legal rights, should something go wrong with treatment.

Dental patients may go to different general dentists for various reasons, including lack of adequate insurance or geographic convenience. You may experience problems when you agree to treat patients who only present on an emergency basis, but who actually consider another general dentist to be their primary care provider. As the “emergency” general dentist you may be treating the more difficult procedures, but are unable to ensure continuity of care, proper diagnoses, treatment and maintenance.

As the “secondary” general dentist, you may have more of a liability exposure than does the dentist who is only performing maintenance treatment for these same shared patients, as you may be performing the more complex treatment. Good communication between the dentist and patient and between the two treating dentists is essential to combat this problem. Explaining to the patient the importance of continuous care with one practitioner may go a long way to putting an end to the problem. If the situation continues, consider asking the patient to choose who will be his or her primary dentist.

Dispose of old patient charts by burning or shredding them. Do not simply throw them in the trash, as they include confidential information that you have a duty to protect. Hiring records disposal companies that specialize in destroying records by burning or shredding is preferable. Because the Environmental Protection Agency does not permit the burning of radiographs, we recommend shredding them. Whether you destroy them yourself or hire a company, keep a log of which records are destroyed, and when. This practice will assist you in identifying which records are unavailable in the event they are requested later.

When searching for a company to dispose of records, look for companies listed as specializing in legal or law records disposal. This may yield a wider range of options than simply looking under dental or medical records disposal.

Complete patient records include the following:

• A description of the patient's original condition
• Your diagnosis and treatment plan
• Progress notes on the treatment performed and the results of that treatment
• Patient's personal and financial information
• Health history (all questions answered) and regular updates
• Dental history
• Vital and diagnostic signs
• Oral cancer screening
• TMJ evaluation
• Periodontal evaluation
• Diagnostic test findings and exam notes
• Consultant reports, reports to and from specialists and physicians
• Notes describing complaints or confrontations
• Notes about rescheduled, missed or canceled appointments
• Exam notes and treatment notes
• Informed consent discussions and forms
• All radiographs taken at intervals appropriate to patient's condition
• Correspondence to and from the patient inclusive of phone calls, emails, voice messages, letters and face-to-face conversations

If two or more plans cover a child of divorced or separated parents, benefits for the child are determined in this order: 1. The plan of the parent with custody of the child. When parents have joint legal custody, the parent whose birthday is earlier in the calendar year has primary coverage. 2. The plan of the spouse of the parent with custody, if that parent is remarried. 3. The plan of the parent not having custody of the child. However, if a court decree designates financial responsibility for the child’s healthcare expenses to only one of the parents, that parent’s plan determines the benefits before any other plan.

Ideally, parents or guardians should accompany their minor children to their dental appointments. However, this may not always be possible. The minor’s parent or guardian must at least accompany the patient to the initial appointment and go through an informed consent discussion about the diagnosis and treatment plan, including regular hygiene visits. At that time, written authorization can be obtained from the parent or guardian for future ongoing treatment, as discussed. However, if the treatment changes from what was covered in the informed consent discussion or complications arise, another informed consent discussion and authorization must take place with the parent or guardian before treating the minor. If you do not have a signed authorization, we recommended that you do not render any treatment. Document all conversations with the responsible adult and any consents, verbal or written, in the patient’s record. Understand that should you treat minor patients without their parent or guardian present, you are the responsible party for the minor from the time of treatment to the minor’s final destination (school, home, etc.).

Yes, assuming the mother already consented to the treatment plan. The minor’s parent/guardian must accompany him/her to the initial appointment, at which time you must have an informed consent discussion about the diagnosis and treatment plan. The parent/guardian must have agreed to the treatment plan prior to authorizing anyone to bring the minor to the office. The non-parent or non-guardian cannot consent to the minor’s dental treatment.

When both parents are involved with the child’s care, have both parents sign or make revisions to the consent to treatment form and the financial agreement, and review them thoroughly. Establish which of the parents will be financially responsible and send financial statements to only that parent. This way, you are removed from payment disagreements between the two parents. Additionally, verify and document whether the person who is financially responsible will also be responsible for treatment decisions. Experience shows that it is best to have the same parent designated as being responsible for both treatment and financial decisions. Regardless, you may provide copies of the child’s treatment record to either parent, unless the custodial agreement states otherwise. It is acceptable to request to see the court order concerning custodial responsibilities.

It depends. While you are not a counselor, sometimes sitting both parents down and explaining how they are placing their child’s oral health at risk inspires a compromise. Tell them that you are considering postponing treatment until they can come to an agreement. It is important to document all occasions where the parents’ disagreements have compromised your ability to treat the child. If you have an office policy in place designating one parent responsible for both financial and treatment decisions, gently remind the parents of this signed agreement and why this policy keeps their child’s best interests in mind. If you do not have a policy in place, send a letter to both parents asking them to clarify which parent will make decisions about the child’s care. If these efforts fail and you cannot get them to agree, consider withdrawing from care. If you do, do so in writing. Remember that you cannot withdraw from care if doing so would cause injury to the patient. Complete any course of treatment you have begun before withdrawing. In the withdrawal letter be sure to include that you will see the patient for 30 days only for emergency visits. Contact the TDIC Risk Management Department for advice on withdrawing.