Three Requests Before the 8 A.M. Patient
At a practice with a stated hygiene production target of $1,400 per day, the office manager hands Danielle, RDH, three requests before her 8 a.m. patient. First, sign a periodontal maintenance note dated three weeks ago for a patient Danielle has never treated, because the note was 'never finished' and the chart must be closed for an audit. Second, re-submit six recently paid prophy claims as periodontal maintenance, since 'the pockets were 4 mm and insurance pays the difference.' Third, witness a signed consent form for a crown the patient already received last week, backdating it to the treatment date. Later that morning the owner dentist arrives for a 7:30 implant surgery at 7:25 with slurred speech and unsteady gait, and tells Danielle to start the patient and 'not to make a thing of it.' Danielle knows he had two DUI arrests in the past four years and has been on a monitoring agreement. The practice's only other dentist is on vacation for nine days.
1. Analyze each of the three record and billing requests against the grounds for discipline.
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1. Signing a note for a patient she never treated. This is falsification of a patient record and a false attestation of care. It also misrepresents who provided the service. Discipline grounds typically include fraud or deceit in obtaining or maintaining a license, falsifying records, and conduct that undermines public confidence in the profession. Her signature would make her the author of the falsehood, not a bystander.
2. Re-billing prophy as periodontal maintenance. Upcoding is insurance fraud. A 4 mm pocket is not by itself a periodontal maintenance indication; the service actually delivered and the documented diagnosis control. Submitting claims she knows are inaccurate exposes her license and the practice to carrier audit, recoupment, and referral.
3. Backdating a consent signature. A consent form signed after the fact is not evidence of informed consent; it is evidence of a cover-up. Witnessing it falsely adds a second misrepresentation.
In each case the lawful alternative exists - late entry marked as late, corrected claim with explanation, contemporaneous consent going forward - and choosing it is the whole point of the question.
2. What should Danielle do about the impaired dentist at 7:25 a.m., given that his partner is away for nine days?
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Stop the case. An implant surgery is an irreversible procedure requiring fine motor control and judgment. Slurred speech and unsteady gait are observable signs that create a reasonable belief of impairment. Proceeding is not loyalty; it is patient endangerment, and her participation would be her own exposure.
Act in the moment. Do not seat or sedate the patient. Notify the patient that the appointment cannot proceed today and reschedule or refer, without speculating about the cause. Remove or secure controlled substances and keys if that is within her authority or the practice's protocol. Document exactly what she observed, when, and what she did - objective findings, not a diagnosis of substance use.
Escalate. The practice's monitoring program, the dentist's monitoring officer or provider health program contact, and the Board are the appropriate channels; the specifics of his existing agreement may already define who must be told. Her own mandatory-reporting analysis should be documented. A nine-day absence of an alternate dentist is a scheduling problem, not a reason to let an impaired operator cut.
3. Danielle refuses the three requests. What should she expect, and how should she protect herself?
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Expect pressure. Production targets, audit deadlines, and loyalty framing are designed to make refusal feel like the deviation. Refusal is the compliant behavior.
Document contemporaneously. A short dated note or email to herself and to the manager: what was requested, what she did instead, and why. Keep it factual and non-accusatory; assume it will be read by a Board investigator.
Use the compliant alternatives visibly. Late entry marked 'late entry' with the date of entry; corrected claim with the reason; new consent form for future treatment. Offering the fix removes the argument that refusing was obstructive.
Know her own exposure. Signing, backdating, or upcoding would put her license at risk independent of the owner's. If the pressure continues, she should consult her own counsel - the practice's lawyer represents the practice - and consider whether a Board complaint about the impaired dentist is required or advisable. She should also preserve texts, since memories fade and screenshots do not.