Medicolegal Considerations

VICTORIA J. STERLING and MYRON R. TUCKER

CHAPTER OUTLINE

LEGAL CONCEPTS INFLUENCING LIABILITY

To understand the responsibility of the dentist in risk management, it is important to review several legal concepts pertaining to the practice of dentistry.

Malpractice is generally defined as professional negligence. Professional negligence occurs when treatment provided by the dentist fails to comply with the standard of care exercised by other dentists in similar situations. In other words, professional negligence occurs when professionals fail to have or exercise the degree of skill ordinarily possessed and demonstrated by members of their profession practicing under similar circumstances.

In most states the standard of care is defined as that which an ordinarily skilled, educated, and experienced dentist would do under similar circumstances. Many states adhere to a national standard for dental specialists. The dentist is considered to have practiced negligently when a patient convinces a judge or jury that the dentist failed to comply with this minimal level of care and that such failure caused a resulting injury.

In most malpractice cases the patient must prove all of the following four elements of a malpractice claim: (1) the existence of a duty, usually implied by the doctor-patient relationship; (2) a breach of the duty—in malpractice, a breach of the standard of care; (3) damages—in nonlegal terms, an injury; and (4) causation, a causal connection between the failure to meet the standard of care and the injury alleged. The initial burden of proving malpractice lies with the plaintiff (patient). The patient must prove by a preponderance of the evidence all four elements of the claim.

First, there must be a professional relationship between the dentist and patient before a legal duty or obligation is owed to exercise appropriate care. This relationship can be established if the dentist accepts the patient or otherwise begins treatment. Second, a breach or failure to provide treatment that satisfies the standard of care must be demonstrated. This standard of care does not obligate the dentist to provide the highest level of treatment exercised by the most skilled dentist or that which is taught in dental school. The standard of care is intended to be a common denominator defined by what average practitioners would ordinarily do under similar circumstances. Third, it must be shown that the failure to provide this standard of care was the cause of the patient’s injury. Fourth, there must have been some form of damage demonstrated.

Dentists are not liable for inherent risks of treatment that occur in the absence of negligence. For example, a dentist is not liable if a patient experiences a numb lip after a properly performed third molar extraction. This is a recognized complication. A dentist can be legally liable for a numb lip if the patient proves it was caused by negligence (e.g., the numbness was caused by a careless incision, careless use of a bur, or other instrument).

Recently, many lawsuits include allegations of unfair trade practices or a breach of contract. Lately, this has become a popular mechanism of the plaintiff’s attorneys to force dentists into settling questionable claims. This charge has traditionally been applied to business transactions and has not normally been used in disputes between patients and dentists. However, some courts have recently ruled that a patient and dentist may actually have a contractual agreement to produce a specific result and that failure to achieve this objective may result in a breach of contract. In many states an alleged promise or guarantee as to the result is not enforceable unless it is in writing. Overly aggressive marketing can lead to contractual liability.

Marketing pressures sometimes lead to written advertisements or promotions that can be interpreted as guaranteed results. Patients who have difficulty chewing after delivery of new dentures, if originally promised that they would be able to eat any type of food without difficulty, might consider such promises breach of contract. Dissatisfaction with esthetics or function is often linked to unreasonable expectations, sometimes fueled by ineffective communication or excessive salesmanship.

The statute of limitations generally provides a time limit for filing a malpractice suit against an individual or a corporation. This limit, however, varies widely from state to state. In some states the statute of limitations begins when an incident occurs. In other states the statute of limitations is extended for a short period after the alleged malpractice is discovered (or when a “reasonable” person would have discovered it).

Several other factors can extend the statute of limitations in many states. These factors include children under 18 or the age of majority, fraudulent concealment of negligent treatment by the dentist, or leaving a nontherapeutic foreign object in the body (e.g., broken bur or file). As mentioned before, the more recent development of trade practices and breach of contract claims can be traced, in part, to a longer statute of limitations period for contract actions and the common treble damages provisions of the deceptive trade practices acts.

RISK REDUCTION

The foundation for all dental practice should be sound clinical procedures. However, properly addressing other aspects of patient care and office policy may considerably reduce potential legal liability. These aspects include dentist-patient and staff-patient communication, patient information, informed consent, proper documentation, and appropriate management of complications. Additionally, clinicians should note that patients with reasonable expectations and a favorable relationship with their dentist are less likely to sue and more likely to tolerate complications.

INFORMED CONSENT

In addition to providing quality care, effective communication and good rapport should become a standard part of office management objectives. Dentists can be sued not only for negligent treatment but also for failing to inform patients properly about the diagnosis, the treatment to be rendered, the reasonable alternatives, and the reasonable benefits, risks, and complications of each. In some states, treatment without a proper informed consent is considered battery.

The concept of informed consent is that the patient has a right to consider known risks and complications inherent to treatment. This enables the patient to make a knowledgeable, voluntary decision whether to proceed with recommended treatment or elect another option. If a patient is properly advised of inherent risks and a complication occurs in the absence of negligence, the dentist is not legally liable. However, a dentist can be held liable when an inherent risk occurs after the dentist fails to obtain the patient’s informed consent. The rationale for liability is that the patient was denied the opportunity to refuse treatment after being properly advised of risks associated with the treatment and reasonable options.

Current concepts of informed consent are based as much on providing the patient with the necessary information as on actually obtaining a consent or signature for a procedure. In addition to fulfilling the legal obligations, obtaining the proper informed consent from patients benefits the clinician in several ways. First, well-informed patients who understand the nature of the problem and have realistic expectations are less likely to sue. Second, a properly presented and documented informed consent often prevents frivolous claims based on misunderstanding or unrealistic expectations. Finally, obtaining an informed consent offers the dentist the opportunity to develop better rapport with the patient by demonstrating a greater personal interest in the patient’s well-being.

The requirements of an informed consent vary from state to state. Initially, informed consent was to inform patients that bodily harm or death may result from a procedure. Informed consent did not require discussion of minor, unlikely complications that seldom occur and infrequently result in ill effects. However, some states have currently adopted the concept of “material risk,” which requires dentists to discuss all aspects material to the patient’s decision to undergo treatment, even if it is not customary in the profession to provide such information. A risk is material when a reasonable person is likely to attach significance to it in assessing whether to have the proposed therapy.

In most states, dentists have a duty to obtain the patient’s consent; they cannot delegate the entire responsibility. Although staff can present the consent form, the dentist should review treatment recommendations, options, and the risks and benefits of each option; the dentist must also be available to answer questions. Although not required by the standard of care in many states, it is advisable to get the patient’s written consent for invasive dental procedures. Parents or guardians must sign for minors. Legal guardians must sign for individuals with mental or similar incapacities. In certain regions of the country, it is helpful to have consent forms written in other languages or have multilingual staff members available to assist with the communications.

Informed consent consists of three phases: (1) discussion, (2) written consent, and (3) documentation in the patient’s chart. When obtaining informed consent, the clinician should conduct a frank discussion and provide information about seven areas: (1) specific problem, (2) proposed treatment, (3) anticipated or common side effects, (4) possible complications and approximate frequency of occurrence, (5) anesthesia, (6) treatment alternatives, and (7) uncertainties about final outcome, including a statement that the treatment has no absolute guarantees.

This information must be presented so that the patient has no difficulty understanding it. A variety of video presentations, including Internet-based interactive education, are available describing dental and surgical procedures and the associated risks and benefits. These can be used as part of the informed consent process but should not replace direct discussions between the dentist and patient. At the conclusion of the presentation, the patient should be given an opportunity to ask any additional questions.

After these presentations or discussions, the patient should sign a written informed consent. The written consent should summarize in easily understandable terms the items presented. Some states presume that if the information is not on the form, it was not discussed. Whether the patient can read and speak English should also be documented; if the patient does not read or speak English, the presentation and written consent should be given in the patient’s language. To ensure that the patient understands each specific paragraph of the consent form, the dentist should consider having the patient initial each paragraph on the form.

An example of an informed consent document appears in Appendix V. At the conclusion of the discussion, the patient, dentist, and at least one witness should sign the informed consent document. In the case of a minor, the patient and the parent or legal guardian should sign the informed consent. In some states, minors may sign the informed consent for their own treatment if they are married or pregnant. Before assuming this to be the case, the dentist should verify local regulations.

The third and final phase of the informed consent procedure is to document in the patient’s chart that an informed consent was obtained after the dentist discussed treatment options, risks, and benefits. The dentist should record the fact that consent discussions took place and should also record other events, such as videos shown and brochures given. The written consent form should be included.

Three special situations exist in which an informed consent may deviate from these guidelines: First, a patient may specifically ask not to be informed of all aspects of the treatment and complications (this must be specifically documented in the chart).

Second, it may be harmful in some cases to provide all of the appropriate information to the patient. This is termed the therapeutic privilege for not obtaining a complete informed consent. Therapeutic privilege is controversial and would rarely apply to routine oral surgical and dental procedures. Third, a complete informed consent may not be necessary in an emergency, when the need to proceed with treatment is so urgent that unnecessary delays to obtain an informed consent may result in further harm to the patient. This also applies to management of complications during a surgical procedure.

It is assumed that if failure to manage a condition immediately would result in further patient harm, then treatment should proceed without a specific informed consent.

Patients have the right to know whether any risks are associated with their decision to reject certain forms of treatment. This informed refusal should be clearly documented in the chart, along with specific information informing the patient of the risks and consequences of refusing treatment. Patients who do not appear for needed treatment should be sent a letter warning of potential problems that may arise if they do not seek treatment. Copies of these letters should be kept in the patient’s chart.

RECORDS AND DOCUMENTATION

Poor record keeping is one of the most common problems encountered in the defense of a malpractice suit. When the quality of patient care is questioned, the records supposedly reflect what was done and why. Poor records provide plaintiff attorneys with an opportunity to claim that patient care also must have been substandard. Even though a perfect record is neither possible nor required, records should reasonably reflect the diagnosis, treatment, consent, complications, and other key events.

Adequate documentation of the diagnosis and treatment is one of the most important aspects of patient care. A well-documented chart is the cornerstone of any risk management program. If dentists do not document fundamental clinical findings supporting the diagnosis and treatment, attorneys may question the need for treatment in the first place. Some argue that if an item is not charted, it did not happen. The following eleven items are helpful when recorded in the chart:

Ten frequently overlooked pieces of information should be recorded in the chart:

Corrections should be made by drawing a single line through any information to be deleted. Correct information can be inserted above or added below, along with a contemporaneous date. The single-line deletion should be initialed and dated. No portion of the chart should be discarded, obliterated, erased, or altered in any fashion. In some states, it is a felony to alter records with the intent to deceive.

REFERRAL TO ANOTHER GENERAL DENTIST OR SPECIALIST

In many cases dentists may think that the recommended treatment is beyond their level of training or experience and may choose to refer a patient to another general dentist or specialist. A referral slip or letter should clearly indicate the basis for referral and what the specialist is being asked to do. The referral should be recorded in the chart. A written referral to a specialist may ask the specialist to provide a written report detailing the diagnosis and treatment plan.

A patient’s refusal to pursue a referral should be clearly noted in the chart. If a patient refuses to seek treatment from a specialist, the dentist must decide whether the recommended treatment is within the dentist’s own expertise. If not, the dentist should not provide this particular treatment, even if the patient insists. A patient’s refusal to seek care from a specialist does not relieve the dentist of liability for injuries or complications resulting from care outside the dentist’s level of training and expertise.

Dental specialists should carefully evaluate all referred patients. For example, extracting or treating the wrong tooth is a common allegation in court. When in doubt, the specialist should contact the referring dentist and discuss the case. Any change in the treatment plan provided by the specialist should be documented in the referring dentist’s and specialist’s charts. To avoid informed consent problems, the patient must approve any revised plan or recommendation.

COMPLICATIONS

Less-than-desirable results can occur despite the dentist’s best efforts in diagnosis, treatment planning, and surgical technique. A poor result does not necessarily suggest that a practitioner is guilty of negligence or other wrongdoing. However, when complications occur, it is mandatory that the dentist immediately begin to address the problem in an appropriate fashion.

In most instances the dentist should advise the patient of the complication. Examples of such situations are loss of or failure to recover a root tip; breaking a dental instrument, such as an endodontic file, in a tooth; perforation of the maxillary sinus; damage to adjacent teeth; or inadvertent fracture of surrounding bone. In these instances the dentist should clearly outline proposed management of the problem, including specific instructions to the patient, further treatment that may be necessary, and referral to an oral and maxillofacial surgeon when appropriate.

It is advisable to consider and discuss alternative treatment options that may still produce reasonable results. For example, when teeth are extracted for orthodontic purposes, the first premolar may accidentally be extracted when the orthodontist preferred extraction of the second premolar. Before removing any other teeth or alarming the patient and parents, the dentist should call the orthodontist to discuss the effect on treatment outcome and available treatment modifications. The patient and parents should be notified that the wrong tooth was extracted but that the orthodontist indicated that the treatment can proceed without significantly compromising the result.

The lack of reasonable modifications of the original treatment plan is more challenging. The dentist may have to consider a more expensive plan, such as implants, and should also consider funding additional treatment.

Another common complication is altered sensation following third molar removal. The chart should reflect the existence and extent of the problem. It may be useful to use a diagram to document the area involved. The density and severity of the deficit should be noted after testing, if possible. The chart should reflect the progress of the condition each time the patient returns for follow-up. Ultimately, the patient may require a referral to an oral and maxillofacial surgeon with experience in diagnosing and treating nerve injuries. In most cases the referral should occur within 3 months after the injury if no significant improvement is seen. Excessive delays may limit the effectiveness of future treatment. Documentation of the patient’s progress helps justify any decision to delay the referral.

PATIENT MANAGEMENT PROBLEMS

COMMON AREAS OF DENTAL LITIGATION

Litigation has involved all aspects of dental practice and nearly every specific type of treatment. A few types of dental treatment have a higher incidence of legal action.

Removal of the wrong tooth usually results from a communication breakdown between the general dentist and oral surgeon or the patient and dentist. When in doubt, the dentist must confirm the tooth to be extracted by radiograph, clinical examination, or discussion with the referring dentist. If opinions differ regarding the proposed treatment, the patient and the referring dentist should be notified and the outcome of any subsequent conversation documented. A short follow-up letter confirming the final decision may also be helpful in documenting this decision. If the wrong tooth is extracted, this should be handled in the manner described previously in this chapter.

Nerve injuries are often grounds for suits, with attorneys claiming that the nerve injuries resulted from extractions, implants, endodontic treatment, or other procedures. These allegations are usually coupled with allegations of insufficient informed consent.

Because nerve injuries are a known complication of mandibular extractions or mandibular implants posterior to the mental foramen, patient advocates claim that the patient had a right to accept these risks as part of treatment. If the dentist can visualize conditions that increase this risk, the patient should be advised and the condition documented. An example would be to note specifically the relationship of the inferior alveolar nerve to the third molar tooth to be extracted, when these appear to be in proximity.

Failure to diagnose can be related to several areas of dentistry: One of the most common problems is a lesion that is seen on examination but is not adequately documented and no treatment or follow-up is instituted. If the lesion causes further problems or a subsequent biopsy documents a long-standing pathologic condition or a malignancy, this may be viewed as negligence. This problem can be avoided by following up on any potentially abnormal finding. The clinician should chart an initial diagnosis or seek a consultation from a specialist. If the lesion has resolved by the next visit, the clinician should record that fact so that the issue is closed. If the patient is referred to another doctor, the referring clinician should follow up to document the patient’s progress, including whether the patient’s condition was successfully treated.

Failure to diagnose periodontal disease is often the area of criticism and legal action. A periodontal examination should be a part of routine dental evaluations and therefore becomes the primary responsibility of the general dentist. The status of the problem, suggestions for treatment, referrals, and progress or resolution of the problem must be clearly documented.

Implant complications or failure is another common area of litigation. As with any procedure, the patient should be informed of the associated reconstruction and long-term outcome of the complication. The need for careful long-term hygiene and follow-up should be explained. The potential detrimental effect of patient habits such as smoking should be explained and documented. Dentists placing implants should consider using a customized consent form, summarizing common complications, and stressing the importance of patient follow-up care and oral hygiene.

Failure to provide appropriate referral to another dentist or specialist can be a source of legal problems. Dentists usually determine the appropriate time to refer a patient to a specialist for initial care or management of a complication. Failure to refer patients for complicated treatment not routinely performed by the dentist or delayed referral for management of a complication frequently becomes the basis for litigation. Referrals to specialists can greatly reduce liability risks. Specialists are accustomed to treating more difficult cases and complications. Specialists with whom the dentist has a good relationship can also diffuse patient management problems by being objective and caring and by reassuring angry patients. The general dentist and specialist may discuss ways of relieving the expense of addressing a complication and completing treatment.

Temporomandibular joint disorders sometimes become more apparent after dental procedures requiring prolonged opening or manipulation, such as tooth extraction or endodontic treatment. Documentation of any preexisting condition in the pretreatment assessment is important. The risk of temporomandibular joint pain or other dysfunction as a result of a procedure should be included in the informed consent when indicated. If the patient is in dire need of care that may aggravate or cause a temporomandibular joint condition, a customized consent form should be drafted and signed. The form should clearly define the problem, giving the patient options and confirming the patient’s authorization to proceed.

WHEN A PATIENT THREATENS TO SUE

Whenever a patient, the patient’s attorney, or any other representative of the patient informs the dentist that a malpractice suit is being considered, several precautions should be taken.

First, all such threats should be documented and reported immediately to the malpractice insurance carrier. The dentist should follow the advice of the malpractice carrier, institutional risk management team, or the attorney assigned to the case. These individuals will usually respond to the threat. Because the first indication of a potential claim is usually a request for records, the office should comply with state law regarding what must be provided (usually copies of care and treatment records, not the originals).

Patients sometimes request the original chart and radiographs for a variety of reasons. The law in most states indicates that the dental office owns the records and has a legal obligation to maintain original records for a specified period. Patients are entitled to a legible copy, and dental offices are entitled to a reasonable reimbursement for the same. Patients do not own the records merely because they paid for care and treatment.

Second, the dentist and staff should not discuss the case with the patient (or representative of the patient) once a lawsuit is threatened or made. All requests for information or other contact should be forwarded to the insurance carrier or attorney representing the dentist. All arguments with the patient or representative should be avoided. The dentist must not admit liability or fault or agree to waive fees. Any such statement or admission made to the patient or patient’s representative may be used against the dentist later as an “admission against the dentist’s interest.”

Third, it is imperative that no additions, deletions, or changes of any sort be made in the patient’s dental record. Records must not be misplaced or destroyed. The clinician should seek legal advice before attempting to clarify an entry.

During the process of malpractice litigation, dentists may be called to give a deposition. This may be as the defendant in a case, as a subsequent treater, or as an expert witness. Although this is common for attorneys, the procedure is often unnerving and emotional for dentists, particularly when testifying in their own defense.

The following are six suggestions that should be considered when giving a deposition related to a malpractice case:

Most anxiety related to litigation comes from the fear of the unknown. Most dental practitioners have limited or no exposure to litigation. One must keep in mind that dentists prevail in most cases. Only about 10% of cases go to trial, and dentists win well more than 80% of these cases.

Unfortunately, a malpractice trial requires a tremendous investment of time, energy, and emotion, all of which detracts from patient care. Most dentists have no choice; they must defend themselves. Dentists who are prepared and who possess reasonable expectations of each step of the litigation process usually experience less anxiety.

MANAGED CARE ISSUES

The influence of managed health care has greatly changed many aspects of dentistry. This includes the doctor-patient relationship and the way decisions are made regarding which treatment alternatives are most appropriate. Dentists are often placed in the middle of a conflict between a desire to provide optimal treatment and the willingness of a health care plan to approve payment for appropriate or needed care.

Traditionally, the patient chooses whether to elect a compromised treatment plan or even no treatment. Under managed care, however, some patients are being forced to accept compromised treatment or no treatment, based on administrative decisions that may be driven more by cost containment pressures than sound dental judgment.

The American Dental Association Council on Ethics, Bylaws, and Judicial Affairs issued the following statement underscoring dentists’ obligation to provide appropriate care:

Dentists have a responsibility to advise patients that a “compromised” treatment plan has been approved by the managed care organization. The dentist should seek the patient’s consent to provide such treatment after the pertinent risks, complications, and limitations have been reviewed, along with an explanation of more optimal treatment options. Dentists should advise in writing, both patients and third-party payers, of reasonably expected outcomes when the appropriate treatment is not available because of improper decisions by third-party providers.

The law has evolved in the area of managed care, and recent court decisions^3,4 create some additional responsibilities for the dentist in advocating for appropriate patient care. Ultimately, each dentist has a duty to treat the patient and not his or her insurance plan. This often entails challenging, in writing, the denial of payment by the plan administrators for the recommended course of treatment by appealing on behalf of the patient for medically appropriate dental care. A letter addressing this situation should include the following elements:

Two other documents are needed to close the loop on the communications aspect of a managed care denial. First, a form for patients to sign that advises them of their diagnosis, recommended treatment, risks of not undergoing the treatment, an acknowledgment that alternative forms of treatment may create less desirable results than those of the recommended treatment, and an acknowledgment that they understand that they can pay for the recommended treatment from their own funds. A second letter should be sent to the patient who refuses recommended treatment that has been denied payment under the patient’s insurance plan, asking the patient to reconsider the decision, expressing the dentist’s concern for the consequences, and urging the patient to appeal the decision directly to the plan administrators.

TELEMEDICINE, ELECTRONIC RECORDS, AND THE INTERNET

Technologic developments have induced changes associated with medical and dental practices. The increasing popularity of computers and the Internet has given birth to new potential duties and liability concerns. Digital imaging, combined with the Internet capabilities for communication and even videoconferencing, has created situations in which patients may receive advice without the traditional doctor-patient interaction. The conversion to electronic rather than paper charts is a growing technology, with many potential applications for a modern dental practice.

The increasing use of electronic records has raised several issues about the validity of office notes, other written documents, and radiographs. As with any medical record it is important that records are not altered, in any way, after they are initially created and placed in a chart or digital file. Although alterations can be made on electronically generated documents, most software packages have tracking mechanisms in place that can detect whether documents, radiographs, or other images have been altered and when this occurred. If a change to an office note or other document is required, this should always be done as an addendum, entered into the record separately, rather than by changing the original document.

Because many offices are completely “paperless,” many documents are signed electronically. Electronic signatures are as valid as the system in place to protect them from fraud, not unlike paper records where a signature can be forged. Most systems have some type of security measures imbedded within the software to protect the integrity of the system. As with many computer security issues this requires the use of user identification and passwords that protect access to the documents by unauthorized individuals. When generated, stored, and protected in the appropriate manner, electronic records are as valid as any other type of medical record.

The Internet access to health care information has changed the dynamics of traditional dentist-patient interaction. A dentist’s legal duty to a patient is currently linked to the existence of a doctor-patient relationship. Determining whether this relationship exists, however, is no longer a simple task. The advent of Internet marketing, telemedicine, and other modes of providing information or advice through an electronic media, without the direct ability to examine, diagnose, and recommend treatment, has clouded the issue of whether a doctor-patient relationship (and a legal duty owed to a particular patient) exists. Courts make decisions that may provide some guidance related to these evolving issues, although disagreement by jurisdictions still exists. One court decision has determined that a physician who consults with a treating physician over the telephone owes no legal duty to the treating physician’s patient when treatment options were relayed during a telephone call.⁵ However, another court ruled that a doctor-patient relationship could be implied when an on-call physician is consulted by telephone by an emergency department physician who relied on the consulting physician’s advice.⁶

Defining clear rules that can be relied upon by practicing dentists who provide direct or indirect advice over the telephone, Internet, or through websites will not be an easy task. Many questions remain unanswered. Do the laws of the state in which the patient lives or those in which the dentist practices actually control this issue? Is the dentist practicing dentistry in another state without a license? In general, courts have found that practitioners must be licensed in the state from which the patient initiates the consultation and that the laws of that jurisdiction control.

Is the advice offered by electronic means intended for general information and not intended to be relied upon by patients or the treating dentist for specific care? If so, then a prominent disclaimer should be posted and acknowledged before proceeding with the interaction. Will the electronic transfer of the information such as the patient’s chart or billing information violate state or federal privacy laws? Under the Health Insurance Portability and Accountability Act (HIPAA) Security and Privacy regulations, duties are clearly defined as described later. Can the dentist protect the information from manipulation or misuse if sent electronically? Today, forensic computer science can track any attempts to change records, and therefore caveats about corrections to documentation apply in the same way they do for paper and film documentation.

Over the coming years, it will be important for practitioners to monitor trends in dental care as the Internet, information storage and transfer, and doctor-patient relationships are affected by advancing technology.

RULES AND REGULATIONS AFFECTING PRACTICE

SUMMARY

In addition to providing sound technical care, the dentist must address several other aspects of patient care to minimize unnecessary legal liability. The dentist should develop the best possible rapport with patients through improved communication and by providing any information that may enhance patient understanding of treatment. Adequate documentation of all aspects of patient care is also necessary. Clinicians face a constant struggle to document quality care and advice to the patient. The law only requires that such efforts be reasonable, not perfect.

This chapter is intended to provide suggestions to be considered by individual dentists. This chapter is not intended to establish, influence, or modify the standard of care. Medical and dental malpractice laws vary from state to state. When confronted with medicolegal issues, all health care providers should consult local counsel familiar with the laws and regulations that apply in their jurisdiction.

REFERENCES