The Record Alteration After a Complaint
A patient, Mr. Reyes, emails the office complaining that during his hygiene visit three weeks ago Ms. Lund "scraped too hard" and that he later developed a gum abscess. He states he is contacting the Arkansas State Board of Dental Examiners. Ms. Lund reviews the chart and sees her note says "SRP UR/UL, patient tolerated well, no bleeding issues" but she now recalls the patient flinched and she stopped early on one quadrant. Dr. Kim tells her: "Just add a line that he refused to let you finish and that he was noncompliant with home care. Backdate it to the visit date so it looks contemporaneous. It'll protect us."
1. Should Ms. Lund make the requested entry? Analyze the record-integrity and due-process issues.
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No. Adding a backdated entry that characterizes the patient as refusing care and noncompliant - when that is not what happened - is fabrication of the clinical record. Patient records must be accurate, contemporaneous, and permanent; late entries are permissible only when clearly identified as late, dated with the actual date of entry, and factually true. Backdating a false statement to the treatment date is falsification, which is unprofessional conduct and can be far more damaging than the original clinical complaint.
Ms. Lund's accurate correction is a properly labeled addendum: today's date, a statement that it supplements the note of the visit date, and the true facts - that the patient flinched, the quadrant was not completed, and follow-up is planned. She should not adopt Dr. Kim's characterization. If Dr. Kim alters the record himself, she should document her own accurate note and preserve a copy of the original.
2. What should Ms. Lund do about the Board inquiry and the patient's abscess allegation?
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She should cooperate fully and truthfully with any Board inquiry. Obstruction, misleading the Board, or participating in a cover-up is independently sanctionable and undermines her credibility on the clinical question.
On the clinical side, the abscess allegation deserves a genuine response: the office should arrange for the patient to be evaluated (the abscess may relate to periodontal condition or an incomplete debridement), document the findings, and communicate a treatment plan. Ms. Lund should review whether stopping early left calculus behind and whether the patient was informed of the incomplete treatment and the need to return. The defensible position is an honest record plus appropriate follow-up care - not a manufactured narrative of noncompliance.