Introduction:
Running a successful Endodontic practice not only requires excellent clinical skills but also entails meticulous attention to legal matters. The implementation of proper legal documentation is crucial for protecting both the practice and the patients. In this blog post, we will highlight various scenarios that emphasize the significance of legal documentation in your practice.
1. Treatment Consent Forms:
One of the most fundamental legal documents in dentistry is the treatment consent form. These forms outline the details and objectives of the proposed procedure, as well as potential risks and complications. By having patients sign these forms, dental practitioners can ensure that patients are well-informed and have acknowledged their understanding of the treatment plan. Treatment consent forms serve as valuable evidence if any complications arise, as patients cannot later claim they were unaware of the risks associated with the procedure.
2. Consent for “CBCT Scan Only”:
Your Endodontic practice should have a separate consent form specifically for Cone Beam Computed Tomography (CBCT) scans if you provide such imaging services to other practices. This document is essential to establish that the responsibility for diagnosing any radiographic findings lies with the appropriate radiologist or referring dentist. Without proper documentation, your practice could potentially be held liable for not informing the patient of any significant findings discovered from the scan you produced.
3. Post-Operative Instructions:
To ensure patients adhere to post-operative instructions for optimal recovery, it’s recommended that your practice have patients sign post-op instruction forms. By obtaining patients’ signatures, practices have documented proof that the patient has reviewed and received these important guidelines prior to providing a printed copy for the patient to take home. This documentation can be invaluable if patients later deny receiving proper post-operative instructions, especially if the treatment outcome is not as expected.
4. Miscellaneous Consent Forms:
In addition to treatment consent forms, your practice should also have miscellaneous consent forms at your disposal. These forms cater to less common scenarios but are equally significant. Examples include media release forms, which allow the use of patient photographs or feedback for case studies or website testimonials. Sedation consent forms should also be utilized if the practice offers oral or intravenous sedation options for patient comfort. Financial consents for “Credit card on file” or payment plans can also be important if this is a service your practice provides. These types of miscellaneous consent forms provide protection and clarity for both your practice and the patient.
5. Witness Present
One of the most critical aspects of clinical treatment consent forms is the presence of a witness. This element holds immense importance because most consent forms rely on the patient’s signature, indicating that they have fully understood the procedure, risks involved, and had all their questions satisfactorily answered. While it may seem convenient to have patients sign treatment consent forms ahead of their first appointment for ease of workflow, there are inherent risks associated with this approach. Firstly, many apprehensive patients prefer to discuss the procedure with the doctor before providing their consent. Secondly, completing the consent form in advance suggests that the patient has not been given an opportunity to ask questions appropriately, thereby lacking an inherent witness to validate the consent form. Ideally, the witness should be either the doctor or a clinical staff member, so we strongly recommend that treatment consents are presented and thoroughly discussed during clinical visits.
6. Legal Review:
To ensure the effectiveness and legality of consent forms, it is highly advisable to seek legal counsel. Lawyers can assist in reviewing the forms, suggesting appropriate language, and including specific clauses required by state regulations. Engaging legal professionals helps guarantee that the practice is adequately protected and that patients receive the necessary information in the most appropriate manner.
7. Team Training:
Implementing legal documentation should involve the entire dental team. It is critical to include team members in the process to ensure that legal documentation becomes a routine part of the patient treatment process. Emphasize that consent forms are mandatory and should be considered as important as financial conversations when preparing patients for treatment. By involving the team, dental practices can further protect the practice and ensure comprehensive patient care.
8. Proper Filing and Digital Documentation:
In the ever-evolving digital age, it is essential for dental practices to adapt their documentation processes accordingly. To ensure that important legal documents are not misplaced or lost, we highly recommend implementing a digital form system. By using tablets or devices, dental practices can gather patient information and consent digitally, resulting in automated and secure documentation. This digital documentation can be effortlessly filed in the appropriate patient charts or easily printed when needed. Ideally, incorporating digital documentation into your practice management software provides seamless integration and streamlined workflows. At DentalEMR, we offer digital forms for new patient aperwork, patient financial agreements, and fully customizable treatment consent forms, enabling immediate logging of vital agreements in the patient chart. However, if this option is not available for your practice, utilizing a digital signature platform like Docusign, PandaDoc, or Formstack can be great alternatives to ensure efficient and secure documentation processes.
Conclusion:
Legal documentation plays a pivotal role in maintaining a compliant and protected dental practice. Treatment consent forms, CBCT consent forms, post-op instructions, and miscellaneous consent forms contribute to patient safety and practice security. Seeking legal review and involving the dental team in this process ensures that legal requirements are met consistently. As dental professionals, it is essential to prioritize legal documentation and embrace it as an integral part of providing quality care to patients.