It is always encouraging to hear that good, comprehensive clinical records can and do assist dental practitioners in successfully defending patient complaints. This case study is about one such positive outcome.
In 2009, the patient lodged a complaint against the dental practitioner with the Dental Board of New South Wales (as it was then known). The patient complained that her health had declined as a result of alleged injuries sustained from implant placement. The practitioner rejected the allegations of complaint and submitted to the Board that his management of the patient had been appropriate and in accordance with established standards of good practice.
In 2010, the matter was considered by the Dental Care Assessment Committee (DCAC) of the newly established Dental Council of New South Wales. The DCAC considered the matter, including reports from the consultants whom the patient had subsequently attended. An independent practitioner also provided an assessment, based on examination of the case records. The DCAC formed the view that the treatment provided was unsatisfactory on the following grounds:
- Failure to record a medical history and patient assessment.
- Incorrect diagnosis and treatment planning, failure to assess bone levels and failure to consider the necessity for bone grafting resulting in unsatisfactory case selection.
- Incorrect placement of implants resulting in perforation of the maxillary sinus and bony floor of the nasal cavity resulting in apparent infection in the maxillary sinus.
The Committee made a recommendation to the Dental Council of New South Wales that the practitioner be directed to refund treatment fees.
The Dental Council sought the practitioner’s attendance before it so that the issues could be ventilated.
At the meeting with the Dental Council in 2011, the practitioner made submissions addressing the grounds above and answered questions from the Dental Council members. The practitioner also supplied the Dental Council with all of his clinical records, radiographs, and other materials.
In the result, the Dental Council decided as follows:
- Council compliments the practitioner on his thorough and excellent records.
- Council does not agree with the decision of the DCAC.
- Council resolves to dismiss the complaint.
The Chairman of the Dental Council specifically commended the practitioner on the quality of his records and said that this matter is likely to be a good teaching tool for the rest of the profession. The outcome is an excellent one for the practitioner and, in our view, the wider profession in that it highlights the importance of good records and demonstrates that good, comprehensive records are important not only in the context of providing good clinical care but are also useful in successfully defending the practitioner against complaints.
For the current requirements in record keeping, practitioners are referred to the “Dental Guidelines on Dental Records” which can be found on the Dental Board of Australia website at www.dentalboard.gov.au.