Backdated Record After a Surgical Extraction Complaint
Dr. Elena Vasquez, an oral surgeon in Annapolis, performed a surgical extraction of tooth #17 on a 52-year-old patient with controlled hypertension. The patient later developed a dry socket and persistent numbness in the lower lip and chin. The patient filed a complaint with the Maryland Board of Dental Examiners. Dr. Vasquez's chart note for the procedure reads only: 'Extraction #17. No complications. Post-op instructions given.' There is no signed consent form, no note about discussing risks of nerve injury, and no record of the patient's INR despite a history of warfarin use. Three days after receiving notice of the complaint, Dr. Vasquez added an entry: 'Discussed risks including paresthesia and bleeding; patient understood.' The entry is dated the day of surgery but was created later. The patient's attorney requests the original record.
1. Evaluate Dr. Vasquez's recordkeeping against Maryland standards. What problems do you see?
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Maryland requires dental records to be accurate, complete, timely, and legible. The record here fails several tests:
- The note 'Extraction #17. No complications' is inadequate for a surgical extraction in a patient on warfarin. It lacks pre-operative assessment, INR, consent discussion, and post-operative findings.
- There is no documentation of informed consent or of the material risks discussed (nerve injury, bleeding, infection).
- The INR is missing despite warfarin use, which is a significant safety omission; the dentist should have consulted the prescriber or obtained an INR.
The later addition is the most serious problem. Backdating an entry to the day of surgery, after a complaint, is falsification and spoliation. A proper late entry must be dated when actually written and labeled as a late entry or addendum. The Board may treat the backdated note as unprofessional conduct and dishonesty.
2. What does Maryland law require for informed consent in this situation?
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Maryland follows the doctrine of informed consent: the dentist must disclose the material risks, benefits, and alternatives that a reasonable patient would want to know. For a surgical extraction of a lower third molar, material risks include permanent or temporary paresthesia of the inferior alveolar nerve, bleeding, infection, dry socket, and jaw fracture. The patient's hypertension and warfarin use add bleeding risks.
Consent must be voluntary and given by a patient with capacity. A signed form is evidence but not a substitute for discussion. The dentist should document what was discussed, not just that a form was signed. If the patient cannot give consent, a surrogate may.
Because the record lacks any consent note, the Board may infer that the discussion did not occur. Dr. Vasquez's later backdated entry does not fix the gap; it makes it worse.
3. How might the altered record affect the Board's disciplinary decision and any malpractice case?
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The altered record can be treated as unprofessional conduct, fraud, or interference with an investigation. The Board may impose stronger discipline because the alteration suggests consciousness of guilt. In a malpractice case, the plaintiff can seek sanctions for spoliation and ask the court to give an adverse inference: the jury may infer that the missing or altered information was unfavorable.
The original record-metadata, audit trail, and any copies-will likely be discoverable. Dr. Vasquez should not attempt to 'clean up' the chart further. She should preserve all versions and consult counsel.
A candid addendum written on the actual date might have been defensible. A backdated note is not.