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You Be the Judge: Referral Slips vs. Progress Notes by Jeffrey J. Tonner, JD

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Header: You Be the Judge
by Jeffrey Tonner

This article is the latest in a series in which readers get the facts behind a real-life dental-board or civil malpractice case, and then compare the verdict they would have delivered with the actual outcome. In consideration of privacy, the names and dates of all involved in this case have been changed.

The case history
"Rose," a 23-year-old patient, exercised extremely poor dental care. She smoked two packs a day, rarely flossed and only occasionally brushed. Her previous dentist restored 14 teeth before she turned age 21.

Three years later she presented to "Dr. Johnson" (the defendant). Many of her previous restorations had accelerated to more advanced conditions because of recurrent carries from her ongoing dental neglect. A treatment plan was developed to extract two teeth and crown 13 others.

Endodontic conditions
In January 2015, three RCTs simultaneously were begun on teeth 13, 14 and 15. Johnson could not fully access the mesial canal of 15 and completed a referral slip, stating "15 refer to endo; calcified canal." The patient never scheduled with the specialist.

The next month, teeth 2 and 3 showed radiographic decay into the pulp. Both teeth were diagnosed with irreversible pulpitis. A second endodontic referral slip was prepared after the X-rays and read, "2 ext? 3 calcified canals." Because of time and money constraints, Rose wanted Johnson, not a specialist, to complete the treatment. He agreed.

Two-step RCTs were begun with an open-and-medicate. Seventeen days later, Johnson completed the endodontics. As anticipated, he could not fully access the mesial canal on tooth 3; however, his progress notes did not reflect this fact. The dentist believed that his previous referral slip adequately covered this situation.

Johnson continued to treat Rose for another 18 months before their professional relationship broke down. She saw a subsequent dentist, who diagnosed incomplete root canal treatment for teeth 3 and 15.

The dental board complaint
In her complaint, Rose stated that Johnson never told her about the unfinished RCTs.

The board reviewed the records, and determined that Johnson did not record either his incomplete work or the fact that he told her she could expect to experience problems with these two teeth without finishing the endodontics. The only mention of calcified canals was found in the referral slips.

Rose had not asked for a refund before filing her complaint, and Johnson had no advance notice that a dental board action was coming.

The board ruling
How would you have ruled on this case? Select one of the four options below:
  1. Dismiss the case.
  2. Dismiss the case and order restitution and continuing education in record keeping.
  3. Uphold the case with restitution and continuing education in endodontic.
  4. Uphold the case with restitution and continuing education in endodontics and record keeping.
Answer D. Uphold the case with restitution and continuing education in endodontics and record keeping.

Answer:
The board found two treatment issues. First, it believed that the progress notes, standing alone, should tell the complete story. The fact that "calcified canals" appeared in the referral slips did not satisfy the record-keeping requirement for this particular board. In the case of tooth 3, the referral slip was prepared based upon the radiographs and before the treatment began. One board member stated that the situation could change once the canal was accessed, and the chart should have noted the final condition. Johnson did attempt to access the mesial canal, but his chart did not reflect whether he improved upon what the radiograph showed. As such, there was no information to inform the reader on the final status.

Second, and more importantly, no writing indicated that the patient was told of this inchoate situation. While the dentist and his assistant testified that Rose repeatedly was warned, the written record did not corroborate their statements.

Practice pointer
As in any legal action, your chart is the single best defense. What should the dentist have recorded here?

"Told pt mesial canal #3 could not be accessed due to calcification. Endo referral given. Told pt she would experience further pain and complications until completed and could lose the tooth."

A more gray-area question concerns whether the office should have followed up on the referral. At the next appointment, the dentist should have inquired and then written this: "Pt stated she did not see the endo. Told her again about complications and tooth loss. Asked her to follow up ASAP."

Some patients never complete endo, once the dentist begins an open-and-medicate or open-and-drain. For the uninitiated, "pain-free" translates to "no further treatment is needed."


Jeffrey Tonner
Jeffrey J. Tonner is a full-time dental-malpractice defense attorney in Phoenix who lectures nationally on dental risk management and record keeping. Tonner created Ideal Charting for General Dentists, a prophylactic system that provides more robust templates, consent forms and update and alert bulletins to help dentists prevent malpractice action before they are filed. For more information, go to thedentaladvocate.com.



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