Dentist Work Release Forms

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					         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
                                                        a Conversation

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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                                             C DA J O U R N A L , VO L 3 5 , N º 8

                          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.

                          Staff Training
                              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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