The Addendum the Dentist Wants Signed
A patient requests a copy of her dental record after a crown seat appointment at which the dentist dropped a bur and lacerated her tongue. The hygienist retrieves the chart and sees that the original note, written the day of the event, says 'bur slipped; small laceration; patient informed.' A later addendum, dated two days after the event, states 'no complications; patient declined follow-up.' The dentist asks the hygienist to sign the addendum as if she had written it at the time of treatment and says, 'The original note makes us look bad.' The patient's attorney has already sent a records request. The hygienist is scheduled to work with this dentist for the next six months and is the sole income earner in her household. The practice has no written records-retention policy.
1. What are the hygienist's obligations regarding the record and the patient's request?
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The record belongs to the dentist or practice, but the patient has a legal right to a copy, and the hygienist must not obstruct that right. She should not alter, remove, or 'clean up' the original note. The original note and the later addendum should both remain in the chart, clearly identified by author and date. An addendum is permissible to correct or clarify, but it must be labeled as a late entry and must not be made to look contemporaneous. The hygienist should give the records request to the dentist or compliance officer and keep a copy of the request. If she is asked to sign a note she did not write, she should decline. If she wrote part of the record, she may sign only her own entry. She should document the request and the dentist's instruction objectively, without editorializing.
2. Analyze the dentist's request and the risks of complying.
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The request asks the hygienist to make a false statement in a patient record and to attribute it to the time of treatment. That is record alteration, which can support professional discipline, civil liability, and potentially criminal fraud. The original note is actually favorable in one sense: it shows the event was recognized and the patient informed. The later addendum, if accurate, can clarify; but backdating it or having the hygienist sign as author is deceptive. If the hygienist complies, she becomes a participant, not a bystander, and her own license is at risk. She should refuse in writing, state that she will not sign a note she did not author, and preserve a copy of the request. She should not discuss the case with the patient's attorney without the dentist's authorization or legal advice; the records should speak for themselves.
3. What should she do if the dentist retaliates?
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Retaliation-threats, reduced hours, or termination-does not make the underlying request lawful. She should keep a contemporaneous log of dates, witnesses, and exact statements, and save any texts or emails. She can report the alteration request to the Board; the Board's complaint process is designed to investigate licensee misconduct, and a patient-safety concern is a legitimate basis. She may also need employment-law advice, but that is separate from her licensure duty. She should continue to provide accurate records for her own patients and avoid signing anything false. If she leaves, she should ensure patient records are not removed and that her departure does not interrupt care. The key is to separate the employment dispute from the professional obligation: her license obligates her to protect the integrity of the record.