The new office I work for has informed refusal forms for everything; radiographs, perio chart, SRP, etc. To me, this is supervised neglect for over two years of no radiographs and one year for perio chart. I had one patient who had not had a perio chart in several years due to refusal. I explained to the patient why it was so important, and she finally allowed me to chart. I know a patient has a right to refuse treatment, but diagnostic tools? Is the office legally covered with signed informed refusal forms?
I, by no stretch of the imagination, have a law degree or am licensed to give legal advice, so to answer this I will revert to the American Dental Association’s statement on informed refusal of treatment and diagnostic modalities.
According to the American Dental Association, an office is not legally covered with signed refusal forms. The ADA states, “If the patient refuses the proposed treatment, the dentist must inform the patient about the consequences of not accepting the treatment and get a signed informed refusal. However, obtaining an informed refusal does not release the dentist from the responsibility of providing a standard of care. If, for example, the patient refuses to have radiographs taken, the dentist should refer the patient to another dentist when the original dentist believes that radiographs are a necessary prerequisite to proper care in that case.” This is stated in the ADA Council on Dental Practice Division of Legal Affairs document on Dental Records (page 16).
What this is basically saying is refusal forms are something to be used, however, there is a point where they become obsolete if a clinician is providing treatment below the standard of care. While patients do have the right to refuse treatment and diagnostic tools, they cannot consent to substandard care. Further, practices have an ethical responsibility to abide by the standard of care.
For further reference, the ADA’s radiograph recommendations can be found here. These recommendations state, depending on caries risk and other factors, radiographs should be taken at a frequency between 6-36 months.
Regarding the frequency of periodontal charting, the Academy of Periodontology states, “Patients should receive a comprehensive periodontal evaluation, and their risk factors should be identified at least on an annual basis.” This includes to “measure probing depths, the width of keratinized tissue, gingival recession, and attachment level; to evaluate the health of the subgingival area with measures such as bleeding on probing and suppuration; to assess clinical furcation status; and to detect endodontic-periodontal lesions.”
Granted, the “standard of care” is the lowest standard clinicians can treat patients to ethically, or a “baseline,” however, we should be striving for even higher. To fall below these standards is not only unethical for patients but can have consequences for the clinician. Considering we live in a litigious society, I would recommend showing the doctor the ADA recommendations for both dental records and radiograph frequency as well as the Academy of Periodontology’s recommendations to avoid potential liability. Updating your office’s protocols will be a win-win situation for all involved!