Ask Kara RDH: Patient Refusal Forms

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The new office I work for has refusal forms for everything; X-rays, perio chart, SRP, etc. To me, this is supervised neglect for over two years of X-rays and one year for periodontal charting. I’m not sure about non-surgical periodontal therapy/SRP. 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 allowed me to chart. I know the patient has a right to refuse treatment, but diagnostic tools? Also, how does that work for non-surgical periodontal therapy/SRP? Is the office legally covered with signed refusal forms?

According to the American Dental Association (ADA), a dental 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.”

To me, what this is saying is that refusal forms are something to be used until it gets to the point of not providing the standard of care. For example, according to the ADA, an adult recall patient with caries or at an increased risk for caries should have bitewing radiographs every 6-18 months. If this patient refuses radiographs they should be signing a refusal form each time they refuse, however, once it hits the point of supervised neglect (i.e., passed 18 months), it may be time to refer the patient to a different dentist, according to the ADA.

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.” I am in complete agreement with you in that patients need thorough periodontal charting at least once per year to provide comprehensive treatment.

As far as a patient refusing non-surgical periodontal therapy/SRPs, again, this falls back to the question of how long do you treat the patient until you get to the point of supervised neglect and not providing the standard of care? In this case, I’ve read articles that suggest doing the less ideal treatment – a debridement. I’m not entirely on-board with this recommendation because the debridement code definition clearly states that it is to be used for patients that have so much debris, a doctor cannot do a proper exam, so I feel this is a misuse of this code. Misuse of codes can lead to insurance fraud, and that’s a whole other can of worms.

Also, a debridement can lead to other issues. For instance, a patient may assume they had their “teeth cleaned” so they are good and need no further treatment; if the tissue heals around calculus it may lead to a periodontal abscess; or the marginal gingival tissue can heal slightly and tighten up, making further instrumentation and thorough removal of subgingival calculus difficult. Because of these reasons, I’m just not on board with not providing definitive and thorough treatment.

In my experience, after so many times of a patient refusing periodontal treatment (or radiographs, etc.), the doctors I’ve worked for would refer the patient to a different doctor/dismiss the patient because they simply couldn’t and wouldn’t take on the liability to the office or risk their license. I’ll be the first to admit this is a tough one because as a clinician, it puts you between a rock and a hard place. It feels wrong not to provide needed treatment, but it also seems wrong to dismiss a patient because they can’t afford or don’t see the value of treatment. There’s just no good answer here, unfortunately.

Many would argue that a medical doctor wouldn’t dismiss a patient because they won’t take their high blood pressure medication or seek treatment for their cancer diagnosis. (It should be noted that some physicians are starting to dismiss patients due to the refusal of treatment). The way I see it is while these physicians still may examine the patient, as a dentist can do too, they aren’t also giving sub-par treatment to compensate for the patient’s refusal, as dental professionals feel they should sometimes do. Some may not agree, but in my opinion, it isn’t an apples to apples comparison.

With all of this said, signed refusal form or not, make sure you document as your license depended on it because it might. Chart notes are legal documents, and we all know if it isn’t written down, it didn’t happen. Document what you explained to the patient and what they said regarding their reason for the refusal. If you can, document their exact words for refusal, accurately and verbatim, using quotations.

While patients do have the right to refuse treatment and diagnostic tools, dental practices and clinicians have an ethical responsibility to abide by the standard of care. Ethically, clinicians should not participate in supervised neglect. We live in a litigation-happy society, so falling back on refusal forms with the assumption the clinician/office is protected, can burn both the office and the clinicians involved.

I’ve written it before, but it’s worth writing again – new to the office or not, you need to be on the same page when it comes to standard of care. You need to sleep at night knowing you provided the best treatment for every patient. And in this case, you need to sleep at night not fearing your license or reputation as a great clinician is on the line. Any ding against your license is public record, and anyone can look it up.

Lastly, I should point out these recommendations reference “standard of care.” Keep in mind 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, as I mentioned before. 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!

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Kara Vavrosky, RDHEP, is a Co-founder and Chief Content Officer of Today’s RDH, a digital media company for dental hygienists, encompassing a daily publication, podcast, virtual continuing education events, and self-study continuing education. Kara is recognized as one of the largest social media influencers in dental hygiene, with a following of over 200,000 dental hygienists and other dental professionals. Kara was recognized in 2020 as one of the Top 100 Women in Media for her entrepreneurship as a Co-founder of Today’s RDH. In 2022, she was recognized by the American Dental Hygienists’ Association for their Standout Seven Award in the Entrepreneur category. A graduate of the Oregon Institute of Technology, Kara has a deep passion for spreading knowledge about the importance of oral health and its relation to systemic health. Kara’s passion extends to helping other hygienists understand the latest protocols, products, and research – all with the goal of pushing the dental hygiene profession forward. Kara currently lives in Vancouver, Washington, just outside Portland, Oregon, with her husband, Ben, and their four Chihuahuas. In her free time, you will find Kara on her quad riding the Oregon Dunes, spoiling her Chihuahuas, and cherishing every moment with her family and friends.