Defensive Dentistry:
Two Strategies to Protect Yourself

When keeping patient charts, there are a few habits that you can develop which will minimize any chance of punitive damages should your records ever be examined in court. Documentation rules the world, and you can be certain that the way that you keep your patient records can make or break your trial's outcome.

Do not mark your charts in the margins.
Juries will award punitive damages if they believe that professional negligence was premeditated. Any sign that a patient's chart was altered can be seen as evidence of deliberate misconduct. Notes made in the margins of a chart could possibly have been added at a later time, a blatant chart alteration. To remain above reproach, practice making all notes in the main page area of your charts.

Be certain that your chart entry dates match your appointment book. A discrepancy in your records can damage your credibility. While a patient may reschedule and appointment dates may change, written documentation may not always reflect these changes, causing your records to be viewed as suspect. Be certain to record all cancellations, reschedules, failures to appear and emergency appointments in your patient documentation. By taking this precaution habitually, you will strengthen your position in court.

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Reference:
Jeffrey J. Tonner, J.D.:
Malpractice: What They Don't Teach You in Dental School, 1996.

More Helpful Resources:

Legal Dictionary
Ky Board of Dentistry
Kentucky Revised Statutes (KRS)-Chapter 313.00
Kentucky Dental Association
Litigation Support from the ADA