Documentation Woes

The North Carolina Court of Appeals recently upheld the Dental Board's decision to discipline a dentist for inadequate charting. After reviewing the dentist's charts, the Board found that there were instances in which the dentist failed to document the reason for prescribing the medication ordered. The Board ruled that the standard of care requires dentists to document the indication for all medications.

The Dental Board has enacted rules requiring a dentist to chart the following:

1. Patient's full name, address and treatment dates,
2. Patient's nearest relative or responsible party,
3. Current health history,
4. Diagnosis of condition,
5. Specific treatment rendered and by whom, and
6. Name and strength of any medications prescribed, dispensed, or administered and the quantity and date provided.

 The Board also recommends the following:

1. Documenting treatment plans,
2. Retaining radiographs, study models, other diagnostic aides, and
3. Retaining the patient's financial records and insurance claim forms.

You will note that the above rules do NOT require the dentist to document the reason for prescribing a medication. The Board admitted that its rules did not address the issue but it argued that failing to document the reason for prescribing a medication constitutes professional negligence. Since the Board has legal authority to discipline dentists who do not meet the standard of care, the Board argued that it had authority to discipline the dentist in the case before the court.

The very same issue arose in a 1996 Colorado case in which the court sided with the Board. However, in North Carolina, our courts typically rule that the law which specifically addresses an issue controls. Clearly, the Dental Board documentation rule is more specific than the standard of care language. Disregarding that tradition, our Court took the side of the Dental Board.

The Dental Board in other cases has demanded more documentation than its rule requires. It has disciplined dental professionals for failing to:

1. Document the fact that they have told the patient about an unexpected finding or event such as a root tip left after an extraction,
2. Record the date of patient health histories,
3. Record periodontal pocket depths,
4. Record the fact that they have informed the patient about the risks, benefits and alternatives to treatment plans,
5. Document the name of the provider who treated the patient,
6. Document the reason for extracting a tooth, and
7. Document clear indications for prescribing narcotics.

Perhaps the Dental Board could consider amending its rule to state that dental professionals must meet the standard of care in their charting. The rule would then state that required documentation includes, "but is not limited to the following." Such an amendment would alert the dentist that the items listed in the rule were not the only things that must be charted.  Such an amendment would also allow enforcing updates to the standard of care without having to go through the process of amending the documentation rule each time the standard changes.  

I understand that the dentist in this case is asking our State Supreme Court to reverse the decision of the Court of Appeals. I will keep you updated on the case. Meanwhile, dentists and other health care providers should remember that their documentation must include the reason for any treatment rendered, including medications.