If you’re facing a dental malpractice claim, your patient’s records can become one of the most essential pieces of evidence you have to defend yourself against the patient’s allegations. As a result, protecting these records is one of the most critical steps you can take as you prepare your defense.
The Role of Dental Records in Malpractice Defense
In a dental malpractice case, a patient’s dental records provide the primary source of documentation regarding the patient’s care and the dentist’s decision-making process. Patient records will contain X-ray scans, progress charts, treatment notes, diagnostic reports, informed consent forms, and correspondence between the dentist and patient.
Parties will refer to the patient’s records to see what treatment they received and to understand the dentist’s decision-making process. A patient alleging malpractice may use their records to show they received inadequate treatment or that their dentist negligently diagnosed or prescribed treatment. Conversely, dental records can demonstrate that a dentist adhered to the applicable standard of care in treating the patient. Thus, incomplete or inaccurate dental records might weaken your defense against a malpractice claim.
Legal and Ethical Obligations for Recordkeeping
State and federal law govern the maintenance of dental records. For example, state laws and dental board regulations may specify the types of patient records that dentists must maintain and the retention periods for these records. Federal law, particularly HIPAA, governs the confidentiality of patient records, establishing standards for protecting the transmission of patient information and ensuring authorized access to records.
Improperly destroying or disclosing dental records can lead to legal complications for dentists facing malpractice claims. For example, failing to retain patient records in accordance with the law or in anticipation of potential malpractice litigation can lead to spoliation sanctions that may jeopardize a defense. Improper handling of documents can also lead to disciplinary actions or other civil litigation under HIPAA.
Common Recordkeeping Mistakes That Hurt Malpractice Defenses
Common recordkeeping mistakes that can hurt dentists’ malpractice defenses include:
- Missing informed consent documentation
- Inconsistent entries
- Evidence of altered documentation, such as metadata in electronic records
- Failure to keep post-treatment communications
- Inadequate charting of complications or follow-up care
Issues or inconsistencies with a patient’s dental records may give plaintiff’s counsel grounds to challenge the dentist’s credibility or suggest that the dentist may have tried to cover up unfavorable information.
Dental practices can reduce the risks of record-keeping mistakes through proactive auditing efforts to ensure that patients have complete records and provide regular staff training on state and federal laws and regulations governing patient records.
Best Practices for Protecting and Maintaining Dental Records
Here are some important best practices you can follow to protect patients’ dental records:
- Keep records in a clear, chronological format
- Avoid handwriting records whenever possible to ensure records remain legible
- Adopt secure digital recordkeeping systems that provide audit trails to record access to or alteration of records
- Back up electronic records periodically
- Implement policies that restrict access to patient records to authorized personnel on a need-to-know basis
- Document or take notes of all patient communications, including when discussing treatment and potential risks
Responding to a Malpractice Claim or Records Request
Have you received notice of a malpractice claim or a request for patient records during a malpractice case? If so, you can protect yourself by taking the following steps:
- Secure the patient’s file to prevent alterations or additions once you anticipate or receive notice of a malpractice claim
- Contact your malpractice insurer
- Only provide copies, not originals, of the patient’s records in response to lawful requests
- Consult a dental attorney for advice regarding when you may disclose patient records under HIPAA and related state laws
Contact a Dental Attorney Today
If a patient has accused you of malpractice, a critical step in preparing your defense is the protection of your relevant dental records. Contact Mahan Law today for a confidential consultation with a dental attorney to learn more about how you can do this and how it can help in your defense.
