The purpose of this risk management/practice management subject is to assist you in better understanding the value of informed consent and how it can be accomplished.

The verbal portion is your discussion with the patient about the conditions present, any appropriate alternatives for treatment and the proposed treatment plan. Let's use a missing tooth as an example.

The discussion should include:

1. The problem/conditions present - missing tooth #30 and any other.
1. Tipped adjacent teeth #'s 29 & 31
2. Condition of those teeth (decay, recurrent decay, fx filling, etc.)
3. Periodontal condition
4. Radiographic findings
5. Any other finding related to treatment of the condition
2. Alternatives for Treatment.
   1. Partial denture - removable with metal clasps or other
      1. Risks
         1. Removable: Less stable and has movement
         2. Collects food and decay may occur
         3. Can fracture
         4. May require additional treatment, remake
         5. Requires periodic adjustment
         6. Requires other teeth to be crowned or altered for proper fit
      2. Limitations
      1. A substitute for natural teeth
      2. Takes time to learn to use, everyone is different
      3. Has movement/less stable
      4. Requires good home care
      5. Must be removed and cleaned
      6. Applies leverage to the teeth it attaches to
      7. It may not be successful for you
      8. Investment is less/cost estimate

   2. Implant placement and crown. A replacement for the missing tooth is placed in the bone and with proper healing, a crown is added to the implant.

      This option should be presented if an implant has been determined to be an appropriate option for the patient's condition. You need to consider their overall health, smoking, diabetes, home care, periodontal disease and bone support, bruxism, occlusion. Advise the patient if they are not a candidate and why.

      1. Risks
         1. This is a surgical procedure with attendant surgical complications (bleeding, infection, nerve injury, etc.)
         2. Implants can fail but the success rate is high
         3. May require removal/replacement in future
         4. The process will take time to complete/give an approximate
         5. Numbness (temporary or permanent)

      2. Limitations
         1. Only a replacement for a natural tooth
         2. The crown can fracture
         3. The implant fixture can fracture
         4. Home care must be maintained
         5. May require future maintenance care
         6. Bone loss around the implant
         7. Investment is greater/cost estimate
         8. Chewing improved but not like natural teeth

   3. What happens if nothing is done?
      1. Tipping and drifting will increase
      2. Change in the bite
      3. Periodontal changes in adjacent teeth
      4. Limited chewing
      5. Additional cost to correct
      6. More teeth involved to correct the problems

3. Recommended treatment
   1. Bridge #29-31
      1. Type-cosmetic, gold
      2. Risks
      1. Additional treatment, endo possible due to multiple treatments on same tooth
      2. Remaking in future depending on patient's oral health
      3. Recurrent decay possible
      4. Requires good home care
      5. Tooth reduction of teeth adjacent to space
      3. Limitations
         1. Cannot floss between the teeth
         2. Involves two other teeth
         3. A substitute for natural teeth
         4. Requires maintenance care
         5. Cost estimate

The dentist is ultimately responsible for the informed consent. The staff can play a part in giving the verbal section, but the dentist should be involved in the process. The dentist must be certain he has answered all the patient's questions.

After the verbal discussion, it is advisable to utilize a signed written consent form. For implants, a complex patient/complex crown and bridge work, a signed consent form is especially important for the patient's understanding and your protection. An example of a consent form can be obtained by clicking on the documents below. Contact the Trust's Administrator for an informational informed consent packet to help you develop your own forms.

Can only verbal consent be used? The answer is "yes", but it provides a lower level of protection when compared to a written document. Your records must reflect the discussion in some detail, including the patient's acceptance of care and notes should reflect that a discussion was made that included the recommended care, the options, the risks and limitations of both, plus what may happen if nothing is done about the problem. This should be accompanied by a written treatment plan.

Other informed consent documents that can be used are:

1. Brochures
2. Handouts
3. Written treatment plan
4. Treatment plan letters
5. Videos/CD's
6. Photograph
7. Models

It is not uncommon to receive a request for patient information. The request can come from the patient, spouse, insurance company, attorney, or another dentist/health care provider.

The purpose of this risk management/practice management subject is to assist you in determining how to respond to a request for dental records/dental information.

1. Let's begin with a request by your patient. The request may come by telephone or in a letter asking for a copy of "my record".

   The Dental Practice Law says the patient is entitled to a copy of their record with an appropriate signed and dated authorization/request and at a reasonable cost and with a reasonable time to prepare the records.
   The Dental Practice Law

   Suggestions to manage the request:

   1. Document the request in the progress notes.
   2. A request for a copy of the record means a copy of the entire record. That means everything between the front and back of the folder.
   3. If the record is lengthy (many x-rays, pictures, etc.), you should contact the patient and ask what they wish to have, then proceed.
   4. You may charge a reasonable fee. Click on the guideline (See Page 16 of 19) for further information on charges. In some instances (going to another dentist, dissatisfied with care for any reason), you may simply want to expedite and waive charges.
   5. You cannot withhold the records for an owing balance, but you can for failure to pay the charges of reproducing the records. If the records are needed for immediate treatment, it is not advisable to withhold them for copying expenses.
   6. If you mail the records, send with a confirming letter. If the patient picks up the record then note in the progress notes.

2. Let's consider a request from a third party accompanied by a signed authorization/release.

   Suggestions to manage the request:

   1. Read the release carefully to see what is being requested.
   2. Check the release for the patient's signature or a person who has authority to release the patient's record.
   3. Review the cover letter as to why the records are requested and directions related to payment for the records.
   4. If the record is lengthy (models, x-rays, pictures, etc.), you may wish to contact the requesting party to see what exactly they want. Be able to provide the cost at that time.
   5. Provide only those documents that are authorized in the release. If there are any other items, an additional release needs to be executed covering those items.
   6. You may charge for the records and refer back to the earlier discussion on that subject.
   7. Make good legible copies and send with a cover letter acknowledging satisfying the request. You may wish to courier, registered mail or express with a company that can track the documents.

3. Now let's consider a request or subpoena you receive from a third party without a signed authorization/release.
   1. Request from a third party
      You should not release patient information without a signed authorization/release or Court Order.
   2. Subpoena from a third party
      You cannot release patient information without a signed release or Court Order. This applies even if a subpoena has been issued. A subpoena does not authorize the disclosure of patient information when it is not accompanied by a release or Court Order. You may be required to appear pursuant to the terms of a subpoena, but you cannot release any patient information. You should contact the party requesting the information and advise them that you cannot release patient information without a signed authorization/release or Court Order. Do not release patient information until you receive the appropriate documentation.

What about the original x-rays?
The original record is your property and that includes the x-rays. However, if a subsequent treater wants to review the original x-rays, there is a provision under the Practice Law that addresses how this is to be done. Please click(See page 34 of 38 Rule XXV #A.) for the text of this provision.

An insurance company wants my records. What now?
Generally, the patient signs a release section as part of their agreement to allow the company to gather records, if necessary. Should you not have any indication of this in the documents from the Plan, contact the company or ask for a signed release by the patient.

I need to obtain records from another dentist or third party so what do I use?
Click here for Records Release - Trust

I have never sent anything other than x-rays to a dentist. Am I in error?
Yes. See the Dental Practice Law(See page 30 of 34 25-1-802, #b 1) previously discussed.

Should I add additional information about the care when sending the records?
No. Submit only what is requested without any further commentary.

Can I find out why the company or attorney is making the request?
Yes. A simple phone call acknowledging the request and release to let them know you will be providing the records will give you an entre' to ask if this request involves your care.

The Dental Practice Law

It is the policy of the Colorado State Board of Dental Examiners that the patient be provided with the necessary information to make an informed decision regarding their dental treatment. Failure to do so can be a violation of the .