Are you ready for a lawsuit?
Dentistry is one of the most litigated professions.
It’s true…
The reality for most dentists is that they can expect to be named in two or more lawsuits during their career, with most involving negligence claims related to the delivery and management of patient care.
Did you know that “documentation issues” account for 1 in 3 negligence claims*?
… and account for one-third of the money paid out to settle dental negligence claims?
(*MedPro Understanding Dental Malpractice Cases: Answers to Common Questions)
Today, more dental practices use digital technology to document and deliver patient care than ever before – and the “electronic dental record” has virtually replaced traditional paper and film as the preferred documentation choice.
In a negligence claim, every dentist is required to furnish copies of the patient’s dental records. These records are handed over to the patient’s legal representatives, who scrutinize them for potential discrepancies, omissions, or fraudulent entries that can be disputed in court or used to support the negligence claim.
When a dentist is named in a negligence case, their electronic dental records will be questioned and contested.
Those dentists who can demonstrate that their electronic dental records contain a complete, accurate and faithful representation of the events are more likely have favorable outcome in a legal challenge.
Documentation Issues in Negligence Claims.
A lack of effective documentation is common in dental malpractice claims with omissions, gaps, and timing issues the primary cause.
- Omission – a lack of detail or too little information in a patient note.
- Gaps – failure to include notes about a patient encounter. (e.g.: failure to document a follow up phone call or conversation with the patient)
- Timing – late entries. (e.g.: altering records that pertain to the incident in the lawsuit and the plaintiff in general. Altering your dental records will almost certainly have consequences, which can affect litigation.
So, before a legal challenge comes knocking on the door, every dentist should have established written procedures regarding how their electronic dental records are managed and stored.
..and every dentist should conduct a quality audit of their current documentation procedures and develop a remediation plan.
SIGNING YOUR DIGITAL NOTES
Sign your electronic notes in a consistent and timely manner.
An unsigned or “unlocked” clinical note is an open-door for plaintiff arguments in a negligence claim. Even if your clinical note is accurate and complete, because it was left unsigned it can be challenged. This puts the the onus you to prove that the note is original and remained unaltered.
When you electronically sign (“lock”) your clinical notes, you are attesting to the authenticity and accuracy of the transcript. This can demonstrate in court that your notes were not modified or altered since they were first entered.
If you are named in a negligence claim, do not alter or change your clinical notes after the fact.
Speak with your attorney before changing or adding notes to the plaintiff’s dental records.
What does MedPro recommend?
Med-Pro (a major underwriter of dental malpractice insurance) has an excellent “documentation checklist” for dentists and dental specialists that you can download using the link below.
https://www.medpro.com/documents/10502/2899801/Checklist_Documentation+Essentials.pdf
Digital Forensics can find treasure troves of data on a Dental Computer.
In my practice, I use digital forensics to examine the data and metadata created by dental software programs that dentists use each day.
In cases of embezzlement or unethical business conduct, digital forensics is used to examine the financial and transactional data to uncover evidence of theft and identify the person responsible.
In a negligence claim, digital forensics is used to examine data and metadata surrounding clinical records, radiograph images, and system logs to establish a trail of evidence. This can help attorneys reconstruct events, verify the accuracy of claims, and substantiate or deny witness accounts.
If you have questions, or need help in implementing any of the suggestions in this article, contact me for assistance.
