Thou Shalt Chart!!!

Another  Sad Charting Failure

          How important is charting?  According to the Hebrew Bible, even the Lord God Himself charted important information.  He didn’t simply tell Moses the laws that would govern His people.  He wrote them down on “tables of stone.” In the health care business, we all know that “If it wasn’t charted, it wasn’t done.”  Ignoring that rule cost one California dentist his license.

Dr. L was a general dentist who limited his practice to dental implants and oral surgery.  His patient presented complaining of pain around tooth #14.  She had no complaints of lower-tooth pain.  Yet, Dr. L convinced her to let him pull her lower left and right wisdom teeth in addition to tooth #14.  He removed all three teeth the day she first came to the office.

Dr. L anesthetized the patient at 12:20 pm but did not begin the surgery until 2 pm.  He performed a coronectomy on tooth #32 and pulled teeth #14 and #17.  He placed bone-grafting material at each site.  After the surgery, the patient had increasing pain.  That pain has continued for more than 4 years.

The Board found the following errors among others:

1.      After the surgery, Dr. L did not conduct a follow-up call or perform a postoperative examination.

2.     Dr. L did not record or monitor the patient’s continuous oxygen-saturation levels or respiratory rate.

3.     He waited too long after administering anesthesia to begin the surgery and kept the patient anesthetized too long.

4.     He failed to record the patient’s preoperative medical history.

5.     He failed to document his preoperative exam findings.

6.     He failed to obtain consent to perform the bone grafts.

7.     He failed to document the use of a barrier to close the bone-graft sites.

8.     He failed to record the type of biomaterial used for the bone graft.

9.     He failed to record the type of fluids infused during the surgery.

10.  He failed to obtain and interpret a 3-D scan before performing the coronectomy.

11.       He misdiagnosed root resorption.

12.       He had no clinical indication for performing a graft at tooth #17.

Dr. L argued that while he may have failed to document some of the above actions, he did perform them.  The Court ruled, “The lack of documentation corroborating Dr. L’s testimony is itself substantial evidence that he did not perform the acts he claims.”

The Court upheld the revocation of Dr. L’s license.

Thanks for reading.  Remember – write it down!

Patrice Walker