Standards of Care, Recordkeeping, and Informed Consent
What this domain tests
The standard of care, informed consent, and clinical records that prove what happened.
Core rules
- Standard of care: the degree of care, skill, and judgment that a reasonably prudent dentist in the same or similar community would use.
- Informed consent: diagnosis, nature of proposed treatment, material risks, benefits, alternatives, and consequences of no treatment; document who consented and when. For minors, obtain consent from a parent or guardian.
- Record content: history, clinical findings, diagnosis, treatment plan, anesthesia, radiographs, medications, referrals, and patient instructions.
- Retention: keep records at least five years after the last treatment; for minors, at least five years after reaching majority. Release copies on valid authorization; never alter retroactively.
Worked example
A patient refuses a recommended radiograph. The dentist should document the recommendation, the reason, the risks of declining, the alternative accepted, and the patient's refusal. If the patient later claims the dentist never warned them, the contemporaneous note is the best evidence. A consent form signed before the discussion, or with blank fields, is weak.
Traps
Using a generic consent form as a substitute for a discussion; writing patient understands without specifics; backdating or adding late entries as if contemporaneous; releasing records without authorization; keeping records only until payment clears.