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Managing dental records
a result, it’s much better to take preventive steps than to undergo the aftermath of financial crimes against your practice.
TDIC Risk Management Staff: Accounting controls can prevent dishonest behavior. J Calif Dent Assoc 43:461, 462, 464, 2015 Reprints not available
Managing dental records Background.—A situation is proposed where an orthodontist is providing a consult for a patient. He obtains photos and has the patient complete all the paperwork. The patient then decides to leave and demands that the clinician give her the paperwork and destroy all photos. The wisdom and legal implications of obeying this demand were analyzed. Analysis.—Legally, it’s important to state that the same tenets apply regardless of whether or not a fee was charged. Therefore whether a fee was charged or not is immaterial. The most significant factor would appear to be whether or not a doctor-patient relationship was established. The elements of a doctor-patient relationship are the presence of a bilateral consensual agreement by which the patient came to the doctor seeking a consultation or treatment and the doctor agreed to accept the individual as a patient and intended to minister appropriate medical or dental services based on the patient’s initial presentation. The patient in the example had voluntarily sought out the dentist and was able to consensually enter into a legally recognized doctor-patient relationship. For those who see a doctor-patient relationship existing, the existence of such a relationship gives rise to a duty of the doctor to conform to a specific standard of care related to establishing a diagnosis and treatment plan. However, neither the doctor nor the patient has consented to any form of treatment. The patient is essentially shopping for an opinion regarding a need, and the doctor has performed the services needed to diagnose the patient’s condition and develop a plan to address the need. This required obtaining diagnostic records. The physical records should be retained as evidence supporting his diagnosis and treatment plan. Legally, although the patient owns the information in the records, the physical records belong to the doctor, who is obligated to give the patient a copy if it is requested. Those who see no doctor-patient agreement in existence argue that such a relationship is impossible until
the patient agrees to proceed with treatment and active treatment is started. Simply proposing a diagnosis and treatment plan does not indicate that the clinician owes a duty to the patient to conform to an established standard of care. Therefore there is no potential liability, and the records can be given to the patient for her to destroy if she wishes. She may watch as the dentist deletes all the computer files. Administrative Ramifications.—Assuming that a doctor-patient relationship does exist, each state dental practice act or public health law has a provision regarding how long medical records must be kept. The definition of records includes photographs, radiographs, models, clinical examination data, clinical notes, communications between the doctor and the patient or legal guardian(s), and communications between the doctor and relevant third parties. The doctor/dentist is considered the legal custodian of the records and required to adhere to the rules and regulations or be subject to administrative sanctions against his or her license. As a result of these rules and regulations, practitioners cannot acquiesce to a patient’s demand to destroy records.
Clinical Significance.—Sometimes patients believe that they own their records and all information pertaining to them or their health status. Legally, this is not true. Patients who attempt to assert their ‘‘right’’ to these records should be informed of the state practice acts and the restrictions on the practitioner’s ability to comply with any demands to destroy them.
Jerrold L: Destroying records. Am J Orthod Dentofacial Orthop 148:184-186, 2015 Reprints not available
Volume 61
Issue 2
2016
67
TDIC Risk Management Staff: Accounting controls can prevent dishonest behavior. J Calif Dent Assoc 43:461, 462, 464, 2015 Reprints not available
Managing dental records Background.—A situation is proposed where an orthodontist is providing a consult for a patient. He obtains photos and has the patient complete all the paperwork. The patient then decides to leave and demands that the clinician give her the paperwork and destroy all photos. The wisdom and legal implications of obeying this demand were analyzed. Analysis.—Legally, it’s important to state that the same tenets apply regardless of whether or not a fee was charged. Therefore whether a fee was charged or not is immaterial. The most significant factor would appear to be whether or not a doctor-patient relationship was established. The elements of a doctor-patient relationship are the presence of a bilateral consensual agreement by which the patient came to the doctor seeking a consultation or treatment and the doctor agreed to accept the individual as a patient and intended to minister appropriate medical or dental services based on the patient’s initial presentation. The patient in the example had voluntarily sought out the dentist and was able to consensually enter into a legally recognized doctor-patient relationship. For those who see a doctor-patient relationship existing, the existence of such a relationship gives rise to a duty of the doctor to conform to a specific standard of care related to establishing a diagnosis and treatment plan. However, neither the doctor nor the patient has consented to any form of treatment. The patient is essentially shopping for an opinion regarding a need, and the doctor has performed the services needed to diagnose the patient’s condition and develop a plan to address the need. This required obtaining diagnostic records. The physical records should be retained as evidence supporting his diagnosis and treatment plan. Legally, although the patient owns the information in the records, the physical records belong to the doctor, who is obligated to give the patient a copy if it is requested. Those who see no doctor-patient agreement in existence argue that such a relationship is impossible until
the patient agrees to proceed with treatment and active treatment is started. Simply proposing a diagnosis and treatment plan does not indicate that the clinician owes a duty to the patient to conform to an established standard of care. Therefore there is no potential liability, and the records can be given to the patient for her to destroy if she wishes. She may watch as the dentist deletes all the computer files. Administrative Ramifications.—Assuming that a doctor-patient relationship does exist, each state dental practice act or public health law has a provision regarding how long medical records must be kept. The definition of records includes photographs, radiographs, models, clinical examination data, clinical notes, communications between the doctor and the patient or legal guardian(s), and communications between the doctor and relevant third parties. The doctor/dentist is considered the legal custodian of the records and required to adhere to the rules and regulations or be subject to administrative sanctions against his or her license. As a result of these rules and regulations, practitioners cannot acquiesce to a patient’s demand to destroy records.
Clinical Significance.—Sometimes patients believe that they own their records and all information pertaining to them or their health status. Legally, this is not true. Patients who attempt to assert their ‘‘right’’ to these records should be informed of the state practice acts and the restrictions on the practitioner’s ability to comply with any demands to destroy them.
Jerrold L: Destroying records. Am J Orthod Dentofacial Orthop 148:184-186, 2015 Reprints not available
Volume 61
Issue 2
2016
67