The Chart, the Subpoena, and the Request to Tidy Up a Note
RDH Karen works in a four-dentist practice in Dubuque. A patient she saw 14 months ago, Mr. Boyd, now has a malpractice suit pending against the practice over a missed periodontal condition. Reviewing the chart, Karen sees her note from that visit: "Prophy. HH good." She remembers - but never wrote - that Mr. Boyd declined probing and SRP because of the cost and said he would "take his chances." The office manager hands her three items at once: a subpoena from the plaintiff's attorney demanding "all records, including the entire family's charts"; a call from Mr. Boyd's new dentist's office requesting records, with a signed authorization; and a request from the dentist being sued to "add to your note that he refused SRP, and date it the day of the visit."
1. What may Karen do about the incomplete note, and what may she not do?
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She may correct the record - accurately and transparently. A late entry is written now, dated now, and labeled as a late entry: "Late entry, [today's date]: on [visit date] patient declined probing and SRP, citing cost; stated he would 'take his chances'; risks of declining were discussed." The original note stays exactly as written. She should record what was actually said and done, not what would be convenient, and she should not embellish with a script she did not use at the time. What she may not do is backdate the addition, insert it into the original note, or replace the chart page - that is falsification, it is usually detectable from metadata, audit trails, or the paper trail, and it converts a defensible documentation lapse into an indefensible ethics charge. The memory-based late entry cuts both ways in litigation: it is better than silence, but a 14-month delay with no contemporaneous note is a fact the other side will use, and she should be prepared to explain the delay honestly.
2. How should the three requests be handled?
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The subpoena. A subpoena from a lawyer is not a court order, and it does not entitle anyone to the entire family's charts. Karen should route it to the practice's attorney and the custodian of records, who will verify the subpoena, notify the patient's counsel as required, confirm whether a protective order or patient authorization exists, and produce only the records the subpoena properly reaches - Mr. Boyd's, not his spouse's or children's. Family members who are not parties have their own confidentiality rights. She should not personally mail anything.
The new dentist's request. A signed authorization covering the relevant records is the normal path; release the records needed for continuity of care, keep a copy of the authorization, and log the disclosure. Treatment needed for continuity should not be held hostage to an outstanding balance.
The litigation request. This is the one to refuse. She may write an accurate late entry; she may not manufacture a contemporaneous refusal.
3. Karen's colleague asks whether the hygienist "owns" her notes and can keep a personal copy of the chart. What is the correct answer, and where does the hygienist's duty lie?
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The patient owns the information; the practice owns the record. The dentist is the custodian, and the hygienist documents as part of the practice's record. Karen does not own her notes, should not keep an off-site personal copy, and should not take chart material to a new employer. Her duty is to document accurately and completely in the practice record, within whatever retention period the Board's rule sets, and to make sure her portion is legible and identified by name and credential - a chart entry signed "K" helps no one in a lawsuit. If she is leaving the practice, she documents correctly and leaves the record behind. When a request for records arrives, her role is to supply correct information to the custodian and to keep quiet about the case outside the proper channels. Loose talk with colleagues about a patient who is suing the practice is its own problem, and it can end up in a deposition.