Orthodontic Treatment Release Form

							                                     Handout #1

                                  Jurisprudence

                              Risk Management

Lawsuits are terribly stressful and time consuming experiences
   How can we protect ourselves as much as possible from being sued ?
   If we are sued, how can we have the greatest likelihood of success ?
   That is risk management


Records
   Your most valuable tool in defending yourself
   Be sure records are complete
   Be sure all records are accurate and readable
   Have a written treatment plan
   Do not write anything that you do not want to show up in court
   Take end of treatment records
   Keep records as long as required by state law
Communicate
   Many lawsuits initiated because of lack of communication
       Many legal experts say that if you talk to the parents and patients (have a
        friendly demeanor), you are much less likely to be sued than if you are
        cold and distant
   Also you must communicate with other professionals involved in the case
   Be sure to communicate the need for the patient back to go back to the GP
    for routine examination and care
Refunding or forgiving fees
   Advantages
   Disadvantages
   Be sure patient signs a waiver
       Include a confidentiality agreement in the written waiver
   Principles vs. practicality
       Consider time, expense and aggravation prior to going after every last
        penny
       Most malpractice suits are initiated as a result of financial issues
Liability of Staff
   You are liable for procedures performed by your staff
       Staff must only perform duties allowed by the Dental Practices Act
       Must be adequately trained and this must be documented
Accidental injury
       Get immediate medical care
       Do not try to hide incident
       Doctor should pay for all medical expenses
       Doctor should show concern an empathy
Extraction errors
   Be careful to check and double check any extraction prescriptions
   Beware of check off forms
       If the wrong tooth is extracted:
Pre-existing and developing pathology
   TMD was the #1 cause of law suits in past
   Now - perio has become the #1 cause of law suits in orthodontic practices
       Must refer patient to GP or periodontist if perio problems exist
       Confirm that patient has seen the doctor you have referred them to
   Root resorption
       Notify the patient
       Proceed depending on severity
   Caries and/or decalcification
       Notify patient and parents
       Obligated to refer to GP
Surgical recommendation
   Find and work with good surgeon
   Always give patient an alternative option
   When sending referral letter, always write "PLEASE EVALUATE"
Aberrant growth
   Always better to recognize possibility and warn patient ahead of time
   Put it in your informed consent
   Inform the patient as soon as you recognize it


When choosing a malpractice insurance company, be sure that you have the
ultimate decision as to whether to go to trial or not
                                    Handout #2

                                  Jurisprudence

            Terminating Doctor/Patient Relationship

On occasion, the orthodontist may find a need to terminate treatment and/or his
relationship with the patient prior to completion of treatment

   Reasons may include factors jeopardizing the patient's health:
   Other reasons may include factors effecting the orthodontist:

Once you take on a patient, you are under contract (written, verbal or inferred) to
perform your duties to complete the case to the best of your ability, guided by
local area standards until one of these occurs:
 Patient's condition no longer warrants treatment
 Doctor and patient mutually agree to discontinue treatment
 Patient discharges the orthodontist
 Doctor unilaterally withdraws from case
    Most potential liability risk

In this litigious era where law suits are more common than braces, the
orthodontist can never fully eliminate the risk of liability in the termination of
the doctor/patient relationship
 Minimize this risk

Structure the termination process with minimal liability risk:
1. Contracts
2. Timing of termination
3. Transition
    Must give patient adequate time to find and contact new orthodontist
    You can give patient the names of orthodontists in your area
    You must maintain the appliances until the patient transfers
4. Records

Procedure for termination
1. Inform the patient and/or guardian of intent to terminate
       If you can not see him in person to terminate:
2. Discuss patient's treatment status and condition
    Treatment progress
    Remaining treatment
    Impediments to success
    Other potential problems
3. Give the patient or guardian a definite date of termination
4. Tell the patient/guardian to immediately find another orthodontist to assume
   responsibility for the treatment
5. Explain that you will maintain the appliances and monitor the patients health
   during this transition period
6. Offer to make copies of the patient's records
7. Confirm by sending termination letter
    Send certified mail - return receipt requested

If patient/parent requests removal of appliances due to termination
 Can be removed if:
 Written release of liability needs to be signed by patient/guardian prior to
    removal
     Should include:
         Request for removal
         Acknowledgement that treatment is not
         Consequences have been explained
         Release of liability of the orthodontist
 Retainers?

Termination for non-payment
 Theoretically, termination of the doctor/patient relationship due to non-
   payment is legal, especially if written into orthodontic contract
 However practically, very difficult to do without consequences
 Most malpractice defense lawyers and jurisprudence experts say to separate
   treatment from finances


Prescreening of patients
The best way to minimize having to terminate the patient/doctor relationship is to
not initiate the treatment of patients who are likely to be difficult or litigious

   Can often, not always, find problem patients by conducting short "Structural
    interview"
    1. What is the reason for seeking treatment?
    2. What are your expectations of treatment?
    3. What are your biggest fears or concerns?

   Look for contradictions
   Look for patients that deal in extremes - see all things in black and white
                          Sample Termination Letter


December 2, 2004


Dear Mrs. Jones,
As we discussed at my office (on the phone) last Wednesday, this letter serves to
confirm that as of January 15, 2005 I will no longer attend to your son Michael
Jones' orthodontic treatment. Because of his lack of compliance, specifically his
refusal to wear rubber bands and his poor hygiene, a good and healthy treatment
result can not be attained. Our treatment to date has accomplished the alignment
of the teeth and the establishment of a Class I occlusion. The overbite has not
been corrected and the gums are very swollen and red.


Since Michael's orthodontic condition requires further care, I strongly recommend
that you immediately find another orthodontist that will continue the treatment.
This should be done in a timely fashion since serious damage to the teeth and
surrounding tissues can arise if the braces are not maintained regularly. I will
assist you in finding another orthodontic office if you so desire.


I will continue to maintain Michael's braces at my office at his regular interval until
this transition is complete. If you would like a copy of his orthodontic records sent
to the new office, please come to the office to sign a proper authorization of
release. A duplicating fee of $100. is payable at that time.


I regret having to take this action but I feel that this is the best option for all of us,
particularly your son.


Sincerely,
                                   Handout #3

                                 Jurisprudence


                            Informed Consent

More dental lawsuits are lost due to improper or inadequate conformed consent
and informed refusal than any other single reason

Informed consent is the principle of law that places upon the orthodontist the duty
and onus to disclose to each patient and/or guardian the potential risks and
consequences that might reasonably result from or be associated with the
recommended treatment
     Consent to treatment is not sufficient

Does informed consent need to be written?
   Most states do require written consent, but it does not have to be formally
      printed
          o “Reasonable, prudent person” rule
          o The more and better you document, the better your chances of
             winning a law suit

Does the written consent need to be a formal form?
   No, but…

Does informed consent need to be signed by the patient or guardian?
   Most attorneys recommend a signature

What should be included in an orthodontic consent form?
   3 categories of risks or outcomes
        o 1. Dire or severe potential risks
        o 2. Material information
        o 3. Common orthodontic consequences
   Should include treatment choices
   Should also include limitations of treatment

Can the same form be used for everyone or should the form be customized for
each patient?
    You can use the same general form, but modify it for each patient

Who should be given (and sign for) the informed consent?
   Patient may sign if he is of legal age
   Parent or guardian must sign if patient is minor
Who should discuss the informed consent issues with the patient?
    Ideally, the doctor should provide this information
Do you need a separate informed consent for each phase of treatment?
    Yes, the orthodontist needs to discuss every phase or placement of new
      appliances prior to performing the procedure

Can I do any treatment without specific informed consent from the
patient/parent?
    Only emergency treatment
    Never place any orthodontic brackets, devices or appliances without
       specifically discussing this and getting an OK

If the patient or guardian does not speak English, does the informed consent
need to be given in his language?
      Yes. The orthodontist is legally required to provide an interpreter at his
        own expense

Is it necessary to advise the patient of informed refusal? (The consequences of
not pursuing treatment)
      You are legally responsible for discussing all negative impacts of not
        following your suggested treatment plan