Case Study C DA J O U R N A L , VO L 3 5 , N º 8
Medical Release Forms:
Not a Replacement for
Once a quarter, the Authored by TDIC risk 47-year-old male patient since those teeth were bothering the
Journal features a management analysts, alleged his dentist practiced patient most, then proceeding with
TDIC risk manage- each article presents a
below the standard of care deep-cleaning appointments before ad-
ment case study, which case overview and real-
provides analysis and life outcome, and reviews
by prescribing ibuprofen dressing the remaining restorative work.
practical advice on a learning points and tips even though he disclosed The dentist told the patient she
variety of issues related which everyone can apply he had cirrhosis and hepatitis C, and wanted to discuss the treatment plan
to liability risks. to their practice. was awaiting a liver transplant. The with his physician to ensure it was safe to
patient spent two days in the hospi- proceed with treatment. She was unable
tal due to gastrointestinal bleeding. to reach the physician but sent a fax list-
The patient presented to the dentist ing the treatment recommendations for
as a new patient. He explained to the the patient and requesting authorization
appointment coordinator that he had to proceed with the extractions. Since
not seen a dentist in at least seven years the patient was complaining of pain, she
and his teeth were bothering him. He prescribed 800 mg of ibuprofen, every
also explained he wanted to restore all four to six hours for discomfort from
of his teeth. The coordinator scheduled the teeth that were to be extracted. The
a new patient exam and allowed extra dentist told the patient she would call
time to discuss potential treatment. him after hearing from the physician to
On the day of the appointment, schedule the extraction appointments.
the patient ﬁlled out the health history The next morning, the fax transmis-
form and indicated he had viral hepa- sion arrived from the physician authoriz-
titis C and cirrhosis, and took Pegasys ing the recommended dental treatment.
and Copegus to treat his liver damage. The appointment coordinator left a
The dentist reviewed the form with him message for the patient to contact the
and noted in the chart the patient was oﬃce to appoint for the extractions. The
on a waiting list for a liver transplant. oﬃce never heard back from the patient.
After taking a full-mouth set of Two months later the dentist re-
radiographs and completing the exam, ceived a letter from an attorney indi-
the dentist recommended extracting cating the patient was suing her for
three teeth due to advanced periodon- negligence in prescribing ibuprofen,
tal disease, endodontic treatment and which resulted in the patient’s hospi-
crowns on several teeth, as well as talization for gastrointestinal bleeding.
several simple restorations. She sug- He demanded $25,000 for loss of earn-
gested starting with the extractions, ings as well as pain and suﬀering.
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C DA J O U R N A L , VO L 3 5 , N º 8
Two months later
the dentist received
a letter from an attorney
During Discovery indicating the patient disease and recommended oﬀering a
The patient’s treatment record only settlement. After negotiations, both
contained four entries and the signed was suing her for parties agreed to settle for an amount
medical clearance from the physician. The lower than originally demanded.
ﬁrst entry was the new patient exam, which negligence in
included notes about the impending liver WHAT CAN BE LEARNED FROM THIS CASE?
transplant, and a fax to his treating physi- prescribing ibuprofen.
cian. The entry made the following day by Medical Release
the appointment coordinator, indicated When requesting a medical clearance
she left a message at the patient’s home listed. For those medications listed, no for a patient from another practitioner, it is
to call and schedule an appointment for contraindications existed for a patient vital for the dentist to include all informa-
extractions. The next entry was three weeks with advanced liver disease. The expert tion necessary. The dentist knew the pa-
later. It indicated another dental oﬃce was did comment that in cases of severe tient’s advanced liver disease necessitated
requesting copies of the patient’s chart and liver damage, a physician should have a a conversation with his treating physician.
radiographs. The ﬁnal entry, which was four conversation with the dentist to discuss However, her impatience led her to fax a
weeks later, read “letter from attorney.” the recommended treatment, rather than medical release form rather than waiting to
The dentist’s own attorney questioned merely signing a medical release form. speak to the physician. Furthermore, the
her about the request for records. She The dentist was aware the patient’s medical clearance form contained medica-
stated she was not aware of the request health necessitated a conversation with tions (anesthetics, pain medications, and
until she received the letter from the pa- the treating physician prior to treat- antibiotics) she typically administered
tient’s attorney, prompting her to review ment. However, since she could not or prescribed when performing extrac-
the chart. The dentist could not conﬁrm speak directly to the physician, she faxed tions. Not only did she not customize the
whether the patient signed an authoriza- a medical release form that indicated clearance form for the patient, she did
tion to release the records or whether the the need for extractions. The fax listed not list the ibuprofen, which was a critical
records had, in fact, been mailed or hand several types of anesthetics she typi- oversight. Be sure to include all prescrip-
delivered. The dentist explained she had a cally used, as well as antibiotics and pain tion and over-the-counter medications you
complete staﬀ turnover since seeing this medications she may prescribe. She did anticipate using during treatment, whether
patient, and the person who would have not feel it was necessary to include the you believe they are contraindicated or not.
handled this request was no longer with ibuprofen and expected the physician Additionally, providing treatment
the practice. She admitted to only learn- to indicate any other contraindicated to patients anticipating an organ trans-
ing the patient had been hospitalized after medications that were not on her list. plant requires antibiotic prophylaxis
receiving the letter from his attorney. The defense attorney questioned because they are usually provided less
The expert witness for the plaintiﬀ the plaintiﬀ’s expert witness about the than 24 hours’ notice prior to surgery.
was a physician. When the plaintiﬀ’s at- role a pharmacist plays when dispens- In fact, one of the protocols for pending
torney questioned him about prescribing ing medication. He asked whether the organ transplant patients is to have all
ibuprofen to patients with liver damage, pharmacist should have ﬁlled the pre- dental treatment performed prior to the
he explained any nonsteroidal anti-in- scription for ibuprofen knowing the transplant surgery. It is best to discuss
ﬂammatory medication is contraindicated patient was taking Pegasys and Copegus the patient’s needed dental treatment
for patients with advanced liver damage to treat his liver disease. The expert with the treating physician and agree on a
regardless of its origin, including the stated that without the patient’s health course of treatment and timeline. Do not
possibility of hepatitis C. The expert was history, the pharmacist would have substitute a form for this conversation.
also critical of the fax transmission form. little reason to contact the prescrib- There were two checkboxes at the
He felt that by not including the prescrip- ing doctor to verify the prescriptions. bottom of the form, “proceed with treat-
tion for nonsteroidal, anti-inﬂammatory The defense attorney was unable ment” and “do not proceed with treat-
medication, the physician was respond- to ﬁnd an expert to support prescrib- ment.” Medical release forms should
ing directly to the list of medications ing ibuprofen to a patient with liver have an area that allows physicians to
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comment on the patient’s overall health
and alert dentists to potential issues.
In cases where the patient’s health is
severely compromised, a conversation
with the treating physician must oc-
cur before initiating treatment of any
kind, including prescribing medication.
Dentists are responsible for ev-
erything that occurs in the oﬃce. For
this reason, it is imperative staﬀ is
properly trained to bring patient is-
sues to the dentist’s attention right
away. These issues include patient
complaints, letters from patients or
their representatives, and any requests
for records. Staﬀ turnover is not a
defense for failing to provide proper
training for each staﬀ member.
Staﬀ should also understand copies
of patient records can be mailed or given
to the patient, a new treating dentist, or
anyone the patient designates as long
as the patient is making the request.
The chart should reﬂect the date the
records were requested, when they were
mailed or delivered, and to whom they
were sent or delivered. It is preferable
to have the patient’s written authoriza-
tion but not mandatory when requested
directly by the patient. When patients
do request their records, it is typically
the ﬁrst sign of discontent. Had the staﬀ
informed the dentist of the patient’s
request, a call to the patient would have
enlightened the dentist to the situa-
tion and possibly headed oﬀ a lawsuit.
When dentists accept patients into their
practices, it subjects dentists to liability,
even before rendering physical treatment.
Any miscommunication on the dentist’s or
staﬀ’s part can create a chain of events that
may lead to serious consequences.
— ROBYN THOMASON
TDIC RISK MANAGEMENT ANALYST
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