Ch. 32- documentation and insurance reporting of periodontal care

Concepts of Malpractice and Tort Law

• standard of care

  • Dental care providers required to exercise same degree of skill and care as could reasonably be expected of prudent dental health care provider of same experience, standing

• Liability

  • Obligation or responsibility to provide services to pt.

• Malpractice

  • Improper or negligent treatment by health care provider that results in injury or damage to patient

• Tort

  • civil wrong where person breaches duty to another

• Intentional torts

  • actions designed to injure another person or their proerty

• Battery

  • Unlawful, unwanted touching or striking another person, with intent to bring about harmful or offensive contact

    • ex. forceful discipline of an unruly child in the dental chair

Concepts of Malpractice and Tort Law

• assault

  • Unlawful threat or attempt to do bodily injury to another

    • ex. treating a minor pt. without proper parental consent

• Infliction of emotional distress

  • ex. talking in harsh voice to unruly child

• Fraud

  • deception to achieve personal gain while injuring another

    • ex. being untruthful on insurance claims

• Misrepresentation

  • Health care provider deliberately deceives pt. about possible outcomes

    • you’ll look like a movie star after ortho treatment

What’s another example of fraud or misrepresentation in the dental field?

• when people get veneers before treating other oral conditions

Concepts of Malpractice and Tort Law

• Defamation

  • communication to third parties of false statements about a person that injure the reputation of or deter others from associating with that person

    • Example- dentist learns that a dental hygienist is making disparaging comments abt his work

• Trespass

  • to infringe on privacy, time, or attention of another

    • ex. discussing a pts. personal information with someone without the pts. permission

Checkpoint: what’s another example of defamation or tresspass in the dental field?

defamation- bad talking boss/coworkers?

trespass- hippa?

Concepts of Malpractice and Tort Law

• Defamation by computer

  • disparaging remarks made in email correspondence

• Negligence

  • failure to exercise reasonable care to avoid injuring others

• Upcoding

  • reporting higher level of service to third-party payer than was actually performed

Concept of professional standard of care

• court compares alleged actions to how other similar experts who act in good faith would perform their duties in same situation

Areas of potential liability

• failure to:

  • Ask and document whether pt. has taken their premed.

  • detect and document oral cancer

  • update, document pts med. history

  • detect and document presence of periodontal disease

• Injuring pt.

• failure to document treatment thoroughly in pt chart or computerized record

• failure to protect pt privacy

  • or divulging confidential pt info

• Failure to inform pt about treatment options and consequences of nontreatment

• practicing outside legal scope of practice

• failure to provide care that meets established standards of care

• ---

Documentation

• dental chart serves as practitioner’s first line of defense in malpractice suit

  • can lose lawsuit due to faculty records, poor documentation

• Compose detailed, accurate note that includes

  • updated medical history, history of CC, dental diagnoses, overall tx plan, and plan for next visit

Documentation guidelines

• format

  • write on proper form or computer document

  • write or print legibly in black or blue ink

  • use correct grammar, spelling, and standard dental terminology

  • date each entry correctly

• Content

  • Only record care you have given or observations you have made

  • Do not make entries for another care provider

  • enter information in a complete, accurate, concise, and factual manner

• Entries may include:

  • reason for todays appt

  • thorough documentation of medical and dental history

  • Pts CC

  • Symptoms reported by pt

  • Findings from clinical periodontal assessment

  • treatment options and recommendations

  • All assessment, educational, treatment services rendered

  • Items given to pt. such as home care aids

  • date or interval of next appointment

  • in liability situation, care or recommendations not recorded were not provided

• Accountability

  • Check pts name on dental record and on form where you are recording

  • always sign first initial, last name, and title to each entry

  • all entries should be written on lines; no entries in margins or below last line

  • Identify each page of record with pts name and chart identification number

  • recognize that pt. record (chart) is permanent

• Timing

  • record information in timely manner

  • document care as closely as possible to time administered

  • do not record care as given before you have provided it

• Confidentiality

  • clinicians using pt records are bound professionally and ethically to keep all information in strict confidence

Appt Schedule and chart entries

• chart entries should be consistent with appt. schedule

• if lawsuit occurs, may cast doubt on reliability of office’s records if tx dates in chart do not match appt book entries

Cancellations and Missed Appts

• record in chart all communication of any type relating to cancellation and missed appts

• Infrequent periodontal maintenance appts can lead to recurrence and progression of periodontal disease

Pt. Noncompliance

• Can lead to disease progression

• Note in chart forms of pt noncompliance such as

  • Inadequate self-care

  • continued smoking

  • failure to regulate diabetes

  • failure to follow specific instructions

Refusal of Treatment

• document pts. refusal of treatment or referral

• recommended to have pt. sign “refusal of treatment recommendation” document

• When pt referred to specialist

  • keep copy of referral eltter in pt. chair

Follow-up telephone calls

• make follow-up calls after long or difficult treatment procedure, and document in chart

• Rule of thumb for hygienists:

  • call any pt that required anesthesia for periodontal instrumentation

Common problems in documentation

• making entries in haste

• skipping lines between entries or writing in margins

  • use all lines to eliminate opportunity for someone to add information adter lawsuit is initiated

• Altering chart entries

  • never

  • if

  • never

  • forensic

Computerized pt records

• electronic health record (EHR)

  • Digital version of pt chart

  • provides real-time data instantly available to authorized users on EHR platform

Advantages of computerized patient records organization and Data gathering

• standardization of clinical data

• enhanced legibility

• easier and faster access to info

• enhanced use of clinical images and radiographs

• offers new ways to analyza clinical info

• potential for greated security of pt. data