The patient's periodontal record. Its legal implications.

Abstract

Records are the backbone of the dentist's defense in any malpractice claim. Cases involving periodontal disease--failure to timely diagnose, failure to adequately treat, and failure to refer--are responsible for a great number of lawsuits against dentists. Since individuals of all ages are susceptible to periodontal disease, all dental records should contain periodontal evaluations data. This article discusses what information should be recorded in order to assist any attorney defending the dentist or, in many instances, how the completeness of such information may deter a plaintiff's attorney from proceeding with a suit. The information recorded should enable the dentist to assess the patient's health, assess the patient's dental status, diagnose any existing periodontal disease, and provide a diagnosis and treatment plan for the patient. In addition, the record must reflect the consent of the patient to the eventual treatment, the progress notes made during treatment, and completion notes at treatment's end. Finally, the dentist must be made aware of the legality of terminating the doctor/patient relationship and the transfer of records. Complete and accurate records can substantiate proper diagnosis and treatment and/or contributor negligence but poor records may be insufficient to protect even an innocent dentist.