Documentation and Scope of Practice Issues in Dentistry

Author: The Doctors Company

This case highlights the importance of both clinical care and operational procedures in managing patient safety and minimizing risk. Here are several strategies dental professionals can implement to avoid similar outcomes:

1. Document All Informed Consent Discussions

  • Clearly explain the treatment plan, risks, benefits, and alternatives to the patient.

  • Ask what the patient expects from the procedure.

  • Record all verbal consent conversations in the patient’s dental record.

  • Obtain written informed consent and retain the signed form.

 (See our article “Informed Consent: Substance and Signature” and find a sample Dental Procedure Informed Consent form on our Informed Consent Sample Forms)


2. Create Clear Staff Protocols for Patient Communication

  • Develop written procedures for handling patient calls, including when to escalate to the dentist.

  • Provide staff training on how to triage calls and document interactions.

  • Ensure timely follow-up is a priority for all patient concerns.

(Learn more in our article: “Telephone Communication for Healthcare Providers: Safety Strategies.”)

3. Maintain Accurate Documentation of All Patient Contact

Every patient call should be documented thoroughly in the dental record, including:

  • Date and time of the call

  • Name of the staff member who received the call

  • Description of the conversation and symptoms reported

  • How the call was managed and to whom it was referred

  • Follow-up plan

(Explore more tips in “The Faintest Ink: Documentation to Defend Quality Patient Care.”)

4. Ensure Staff Operate Within Their Legal Scope

  • Train team members on their specific responsibilities and scope of licensure.

  • Stay current on state regulations regarding staff roles, credentials, and permitted duties.

  • Reinforce documentation and communication standards as part of ongoing team training.

Protect Your Practice and Your Patients

Dental malpractice claims often result from a combination of clinical missteps and communication breakdowns. By strengthening your informed consent process, ensuring consistent documentation, and creating reliable staff communication protocols, you can minimize risk and enhance the overall patient experience.

Need Help with Risk Management or Patient Safety?

The Department of Patient Safety and Risk Management at The Doctors Company is here to help. Call (800) 421-2368 for guidance on best practices, training resources, and policy development.

Disclaimer: The guidelines in this article are not rules and do not constitute legal advice. Providers must use clinical judgment based on individual circumstances and comply with state laws where care is rendered.










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