Recording your way out of trouble

By Dr L

I’ve always kept good notes. We had a great lecturer on clinic at dental school who made sure we wrote everything down all the time so I feel I got into good habits early.

The problem came after I graduated, as I always seemed to be running late. I asked for more time for my appointments, but I didn’t get it, so I started writing my records up at lunchtime or at the end of the day.

I didn’t think this would affect the detail of what I wrote, but I was wrong.

A patient came in for a check-up, there was nothing on their medical history, and they hadn’t been to the dentist for seven years. I did the exam, and everything looked OK. I took some x-rays and there were fluoride bombs on the back teeth. I showed the patient the x-rays and tried to explain what was going on; that the holes were deep and he may need root canal treatment if the nerves of the teeth were affected.  I don’t think he really believed me, as he kept saying he didn’t have any pain. I gave him an estimate, and he booked to have the fillings for the next week.

I put the block in, and opened the teeth up. The cavities were huge and the patient started to feel pain as I removed the soft decay, so I put in another two blocks and a long buccal – three carpules of anaesthetic in total. The fillings were deep, but I didn’t expose. When I sat the patient up, I told him again that the holes were deep and close to the nerves, but that I hadn’t exposed the nerves. I told him he would be numb for a while and that the teeth would hurt when the numbing wore off. I told him the teeth still might die and need a root treatment or even extraction. He listened. He nodded. He said he understood. He thanked me and he left.

I was already running about an hour late, as the extra numbing had taken some time. My next patient was for a surgical extraction, and I ran over into my lunch break. My 2pm patient was waiting when I finished.

I wrote the notes up that night. I spent a lot of time on the surgical extraction notes as it had been for a wisdom tooth and I wanted to make sure that the consent was all documented properly, and all the risks and warnings I’d given.

I wrote down what local anaesthetic I used for the fillings patient, and the materials I used, but I didn’t write down what I told him. I just wrote “deep”.

You know what happened next…

The patient got a toothache and complained about me. He said he didn’t have toothache before he saw me and said I must have hit the nerve, and that’s why he needed so much numbing. He said he had seen another dentist who told him I had filled into the nerves and damaged all three teeth. He had chosen to have the worse tooth extracted because of the pain, and wanted me to pay for an implant to replace it, and for root fillings for the other two teeth. I tried to talk to him, but he wouldn’t listen. He asked to speak with a “senior dentist” who knew what they were doing. My principal told him I had done nothing wrong, but the patient didn’t believe him, and I soon received a letter from AHPRA. Worse day of my life. So I called Dental Protection.

Dr Annalene Weston – dentolegal adviser, Brisbane office

Dr L is one of many practitioners who receive a complaint from AHPRA annually, with dental practitioners currently being the second most complained about profession by percentage. Dr L was asked to provide her records and x-rays and a full summary of what had happened. Her treatment planning was sound, and the decisions she made were good. Sadly, her records let her down as they did not reflect the conversations she had had with the patient and, critically, what risks and warnings she had issued. Dr L showed great insight in her submission to AHPRA by candidly discussing the deficiencies in her record keeping.

AHPRA were fair with Dr L, and on consideration of the fact she was a recent graduate, they proceeded to caution her only (the lowest level of action they can take) and recommended that she undertake some record keeping CPD, which she has.