Consent or refusal: What every dental practice should know

We in the dental field know the importance of accurate and complete documentation. We strive to do our best to “paint a picture” of the patient’s condition, what treatment(s) are recommended and performed, and the dentally necessary reasons for that treatment. If your practice has implemented dental-medical cross coding, then the medically necessary reasons for treatment must also be documented. However, there may be steps that some dental practices are missing — obtaining signed consent for treatment forms and signed refusal of treatment forms.

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Informed consent implies that a patient has been given enough information to make a meaningful decision based on the benefits vs. the risks of a proposed dental treatment. This information is given verbally or on a form. Legally speaking, certain criteria should be met to be a legally sound informed consent. Not all states have specific requirements to follow in this regard, but they do require that some form of consent be obtained for certain types of dental procedures. Often the criteria are set by dentists and their professional organizations. But the law still plays a part by requiring dentists to provide enough information for patients to make informed decisions about their dental care, and this information must be consistent with a professional standard of care. The following should always be included in this information:

· The reason why the dental treatment is necessary
· What the proposed treatment will be
· Any alternative treatments
· The benefits vs. risks of the treatment
· Who will perform the procedure
· A way for patients to ask questions

The question then becomes whether this consent should be verbal or written. It is accepted that verbal consent is often times sufficient for less complex dental procedures. However, documentation of the verbal consent must be thorough. Verbal consent can also be given over the phone, but it must include all of the elements mentioned above and be thoroughly documented.

Major dental procedures are best handled with a written consent. In either case, the information must be presented in clear language that all patients can understand. Keep in mind that some patients may not capture all that is presented verbally. A written form can be easier for some patients to understand. Practices that use specific consent forms for different procedures cover all bases by making sure there is a record of that consent. Practices in a multicultural area should have these forms available in the major languages spoken in that area. These forms should be dated, timed, and signed by the patient, dentist, and witness.

Not all patients have the capacity to provide consent, so practices should obtain consent from someone legally allowed to do so. In addition, parties with power-of-attorney for health care for those patients who are not mentally able should be the ones to give consent when it applies.

We must remember that patients have the right to refuse treatment. Dentists should discuss the risks of no treatment to be sure that the patient understands the consequences. If this fails to change the patient’s mind, then a refusal of treatment form that details the risks of no treatment needs to be given to the patient and handled in the same manner as the informed consent form.

Consent/refusal forms for dental radiographs also require consideration. In 2012 the ADA, in collaboration with the FDA, released updated recommendations for taking dental radiographs. “Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure,” which was updated in 2004, is available on the ADA website, giving patients leverage to refuse dental radiographs.Using a dental X-ray refusal form allows patients to make an informed decision, and gives dental professionals a chance to explain (in detail) how radiographs serve to detect dental problems early.

Both consent and right to refusal forms may include various procedures, from smile makeovers, veneers, dentures, crowns, bridges, and partial reconstruction and complete reconstruction, to nonsurgical periodontal therapy and dental X-rays.

“In the courtroom, medical records are witnesses whose memory never dies.”Pubmed and other sources provide this quote as a reminder of the importance of thorough documentation of patients’ medical and dental records. Legally speaking, if it isn’t documented it may not be considered as done. Today it is absolutely necessary to document discussions with patients in the patients’ records. The use of informed consent and informed refusal forms makes it a certainty that this has been addressed.

Because different types of dental procedures require different types of information to accurately complete the form, there are times when a standard form will not work. Examples of informed consent and informed refusal forms follow. More forms and templates are available by contacting the authors of this article.

Examples:

CONSENT FOR NONSURGICAL PERIODONTAL THERAPY
I have been informed by Dr. ___ that I have periodontal disease, and I agree to the following treatment that includes but is not limited to the following:
1) Nonsurgical periodontal therapy in either one appointment, or two to four separate appointments using:
· Ultrasonic scaling and tongue disinfection with irrigation
· Host modulation – Periostat Rx, literature, and verbal information
· Locally applied antimicrobials in all infected periodontal pockets
· Noninjectable periodontal gel
· Assessment of grinding or clenching habit
· Periodontal risk assessment
2) My treatment can be maintained with routine three-month periodontal maintenance visits with the hygienist
3) I am aware that some areas are more severely affected and referral to a periodontist may be necessary to achieve optimal oral and systemic health.
I am willing to undergo all recommendations and have a good understanding of my periodontal condition and my role in the success of my periodontal treatment.
___________ _______ ______________________________

^{DateTimeSignature of patient or authorized individual}

^{_______________________________}

^{Relationship of authorized individual}
___ The patient or authorized individual has read this form or had it read to him/her
___ The patient or authorized individual states that he or she understands what is stated in the form
___ The patient or authorized individual states that he or she has no other questions

___________ ___________ ______________________________

^{DateTimeSignature of Dentist}

___________ ___________ ______________________________

^{DateTimeSignature of Witness
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INFORMED REFUSAL FOR PERIODONTAL THERAPY
I have been informed by ________that I have periodontal disease, a gum condition that if left untreated can progress and lead to further jaw bone destruction and tooth loss.
I have been encouraged to ask questions pertaining to my gum condition and was informed of the strong correlation between periodontal diseases and other systemic diseases and total body health.
Having been thoroughly informed of my periodontal condition, I voluntarily refuse to undergo periodontal therapy, surgery or referral to a periodontist.

___________ _______ _______________________________

^{DateTimeSignature of patient or authorized individual}

^{_______________________________}

^{Relationship of authorized individual}
___ The patient or authorized individual has read this form or had it read to him/her
___ The patient or authorized individual states that he or she understands what is stated in the form
___ The patient or authorized individual states that he or she has no other questions

___________ ___________ ______________________________

^{DateTimeSignature of Dentist}

___________ ___________ ______________________________

^{DateTimeSignature of Witness}

Marianne Harper is with The Art of Practice Management and can be reached at [email protected]. Colleen Rutledge, RDH, is with Perio-Therapeutics & Beyond and can be reached at [email protected].