Poor records, poor defence

04 August 2009

A dentist carried out a deep restoration in an upper left premolar tooth. The patient returned with symptoms which did not settle and eventually, with full explanation being offered, root treatment was carried out.

Almost immediately afterwards, a cusp fractured from the tooth and the dentist recommended that the only appropriate restorative option was provision of a post crown. The patient did not wish to pay for this treatment as she felt the loss of the cusp had been caused by the dental treatment rather than the gross amount of decay which had previously been in the tooth.

The patient wrote a letter of complaint and the dentist responded, indicating he did not feel the loss of the cusp was his fault and that the patient would be required to pay for a crown if she chose this form of treatment. The patient did not accept this response and raised a complaint with the Ombudsman’s office.

In order to investigate matters the Ombudsman examined the patient’s records and was critical of the dentist’s record keeping. There were no radiographs showing diagnostic working lengths; the dentist had indicated in the records that he had found an obstruction in the buccal canal. There were some figures in the margin of the records, but no indication of what they meant. There was no post-operative radiograph.

When the dentist was asked to explain the record entry, he said that he routinely used an electronic apex locator and the figures in the margin related to the lengths of each canal. The patient had been quite irate about the tooth fracturing and the ensuing discussion with the patient lasted some time, such that the dentist was “running very late”. He therefore did not take a post-operative radiograph and the patient had since failed to return to the practice.

When all this information was relayed to the Ombudsman’s adviser, he remained critical of the record keeping, although he was supportive in the diagnosis and treatment proposals of the dentist. In conversation with the dentist, MDDUS pointed out that a reasonable standard of record keeping in relation to root treatments would include appropriate recording of working lengths, stating whether or not an electronic apex locator was used, and, of particular importance, taking a post-operative radiograph.

Analysis and outcome

On analysing the records more carefully, MDDUS judged that it was highly likely in this case that an expert – instructed by a solicitor acting on behalf of the patient – would be critical of the record keeping with the implication that the standard of treatment was possibly inadequate. In the absence of good information on the dental records, MDDUS would not be in a position to offer a strong defence of the dentist.

Key points

• Ensure that full and complete contemporaneous records are written.
• Records should be both legible and understandable.
• Irrespective of who writes the record it should be checked by the clinician after each patient contact.