"Just Update the Note" After a Failed Implant
The office manager calls the dentist at home on a Sunday. A patient who lost an implant to infection three weeks ago has requested "everything in my chart" and mentioned a lawyer. The manager says: "The note from the post-op visit doesn't mention that we never called her back about the swelling - can I just update that note to say she declined to come in? Also we never got a signed consent for the implant, but I can have her sign one dated before surgery. And she's asking for the CBCT - should we just send a summary instead and charge her a flat $75 records fee?"
1. Evaluate each of the manager's three proposals.
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1. Updating the post-op note to say the patient declined - NO. That is creation of a false medical record. The original note must stand as written. If a fact was omitted or recorded in error, the lawful tool is a separate, dated, signed addendum that identifies itself as a late entry, states what is being corrected or added, and leaves the original entry and its date intact. Nothing may be backdated, overwritten, or deleted.
2. Obtaining a consent now and dating it before surgery - NO. A consent signed after the fact and dated earlier is a falsified document. It converts a documentation gap into an affirmative act of deception.
3. Sending a summary plus a flat $75 fee instead of the record - NO. On a proper written request the patient is entitled to copies of the actual record, including images. A narrative summary is not a substitute. Charges are limited to the actual cost of duplication (plus postage), not a flat administrative or "records" fee.
Why it matters: falsifying or altering records is squarely within the disciplinary grounds of ss. 456.072 and 466.028, F.S., and it destroys the credibility of every other entry in the chart.
2. What should be done now about the record and the missing implant consent?
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Record:
- Preserve the chart as-is; lock or copy the electronic audit trail.
- Add a dated, signed addendum describing, factually, the post-op communications (who called whom, when, what was said) - stated as "addendum added [date], reflecting information not recorded at the time."
- Do not speculate about what the patient "would have" done.
Consent gap:
- Do not manufacture a consent. Acknowledge internally that the file lacks a signed implant consent.
- Determine whether consent was obtained verbally and documented elsewhere (referral letter, consult note, witness). Document the reconstruction honestly, labeled as such.
- Notify the malpractice carrier now and route all communication with the patient's counsel through the carrier/counsel.
- Fix the system: a signed, procedure-specific consent (risks of implant failure, infection, bone loss, alternatives including no treatment) scanned into the chart before the surgery starts, verified at the pre-op huddle.
Retention: the chart must be retained for the period required by Board rule (generally at least four years from the last treatment) - and longer once litigation is threatened.
3. Describe the compliant response to the records request itself: what is produced, in what form, at what charge.
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- Trigger: a written request (or a valid authorization/subpoena) from the patient.
- What: copies of the complete record - all chart notes, periodontal charting, treatment plans, prescriptions, lab work authorizations, correspondence, and the imaging (CBCT in a usable diagnostic format, not a screenshot or a summary).
- When: within the time required by s. 456.057, F.S., after receipt of the request.
- Charge: only the actual cost of duplication plus postage; imaging duplicated at actual cost. No flat "records fee," no charge for reviewing or summarizing the chart.
- Never: withhold the record because of an unpaid balance, or condition release on signing anything.
- Document the date the request was received, what was produced, and the date it was sent.