Standards of Care, Patient Records, and Informed Consent
Standard of care and records
The standard is the care a reasonably prudent dentist would provide under similar circumstances, including adequate diagnosis, treatment planning, and follow-up. The record must be contemporaneous, legible, and complete enough for another dentist to understand the care. Typical entries include medical history, clinical findings, diagnosis, radiographs and interpretation, anesthesia, procedures, prescriptions, referrals, and informed consent. Retention must meet Board rule; minors and certain records require longer retention. Never alter a record after a complaint without a proper addendum.
Informed consent
Consent is a process, not a signature. The dentist should explain the diagnosis, proposed treatment, material risks, alternatives including no treatment, and expected outcomes, then document the discussion and the patient's decision. For significant procedures, written consent supports the record but does not cure a rushed or incomplete discussion.
Worked example
A patient has a mandibular third molar removed. The note says 'consent signed' but no discussion of nerve injury, bleeding, infection, or alternative. When paresthesia occurs, the defense is weak because the record cannot show that the risk was disclosed. The reasoning: the signature proves a form was signed, not that the patient was informed.
Traps that cost marks
Charting only the procedure and not the findings. Backdating or editing notes. Treating a generic consent form as sufficient for every procedure. Failing to document refusal or no-show follow-up.