Documenting Consent and Refusal

What every dental practice should know

Trey Tepichin

Having accurate, detailed documentation is a crucial part of running any dental practice. The notes that we complete are designed to record patients' conditions, recommended treatments, and performed procedures as well as the medical reasons behind these decisions. Although most dental practices understand and carry out the documentation fundamentals, there are some important steps that many dental practices overlook, such as gathering signed consent forms for treatment that will be carried out and signed refusal forms for treatment that has been declined.

Informed Consent

According to the Journal of Oral Hygiene & Health, consent implies that a patient has been given sufficient information regarding the advantages and risks of a proposed dental treatment in order to make an informed, meaningful decision to accept or reject it.¹ The information can be provided verbally or in written form, as long as certain criteria are met from a legal perspective.

When it comes to obtaining patient consent, some states have clear requirements that you're obliged to follow, whereas others are a bit more lax in defining their prerequisites. But wherever your dental practice is based, it's still vital to obtain patient consent, especially for certain types of dental treatments. These include any procedures that are invasive or irreversible.²

It's often dentists and professional organizations who set the criteria that must be met when obtaining consent. However, there are still legal rules and regulations that dictate how much information dentists are obliged to provide to patients about their dental care and how that information must be consistent with a professional standard. When obtaining patient consent for treatment, there are several points that must be covered in order for it to be legally valid, including the following³:

• The reason why the dentist is recommending the treatment
• An overview of what the procedure will involve
• The details regarding any alternative treatments available
• The benefits and the risks of the proposed treatment
• The names of anyone who will be involved in the procedure
• A means by which patients can ask questions

Verbal or Written?

Deciding whether patient consent should be obtained verbally or in writing isn't always as straightforward as it seems. It's generally accepted that verbal consent is usually sufficient for simple, routine dental treatments.² However, the documentation of the verbal consent must be detailed. Verbal consent can be obtained in person or over the phone, but it must include the six aforementioned points and be clearly cataloged.

When information is provided verbally, it's easier for patients to misunderstand or forget certain aspects. This is why verbal consent is best suited to straightforward procedures. When there are a lot of details to convey, obtaining written consent and providing patients with a copy of the form helps provide them with something that they can look at as a reminder. In this regard, obtaining written consent is preferred when major and complex dental treatments are being recommended.

Other Considerations

If your dental practice is in a multicultural area and you treat patients for whom English is a second language, it's important to provide each patient with a consent form in English as well as in their native language. In a study conducted by The University of Western Australia's Dental School, 29% of the patients gave consent for procedures without being fully aware of the potential risks due to language barriers.⁴ Providing consent forms in patients' native languages helps to ensure that they've fully understood everything contained within.

For various reasons, some patients are unable to provide informed consent.⁵ In these cases, dental practices must obtain consent from an individual who is legally permitted to provide it on behalf of the patient. When this occurs, it's important to be clear that the authorized individual is providing consent that is in the best personal interests of the patient.

Whether verbal or written, the information provided during the process of seeking informed consent must be conveyed to patients in clear, nontechnical language that's easy to understand. Although the use of consent forms is helpful for patients, they're even more advantageous for dental practices because they create a clear paper trail that can be provided if your office is ever required to produce records of patient consent in the future.

Refusal

If a patient isn't in pain or doesn't perceive that there is an immediate threat to his or her health, it can often be difficult to obtain consent.⁶ Sometimes, it's simply a matter of "selling" your treatment and waiting until you understand what motivates the patient to accept a better state of health. But other times, you have to acknowledge patients' rights to refuse treatment.

In situations in which a patient refuses treatment, dentists should discuss the risks of refusing it to be sure that the patient fully understands the consequences of such an action. If the patient doesn't change his or her mind, it's important that he or she complete a refusal of treatment form, detailing that he or she fully understands the risks of not undergoing the treatment.

If your dental practice ever becomes part of a legal dispute, being able to produce thorough patient medical and dental records, including signed consent and refusal forms, could be your saving grace. Although memories can be hazy and unreliable, detailed documentation doesn't lie. Therefore, it's vital to document conversations with patients in their records and using consent and refusal forms to provide certainty that the important issues have been properly addressed.

In addition, because many dental practices offer a number of distinctive treatments, it's beneficial to have different consent and refusal forms with details pertinent to each procedure.

Downloadable Forms

Among other sites, the National Network for Oral Health Access's website offers a huge collection of consent forms that you can download, print, and use to acquire informed patient consent within your dental practice.⁷ The consent forms available cover a broad range of dental treatments, and some are even available in multiple languages.

Disclaimer

Please be aware that the information provided in this article should not be viewed as legal advice. It is simply a guide to help you in gaining proper consent and refusal from your dental patients. You should always seek appropriate legal counsel regarding your individual practice's specific situation. Furthermore, this article is directed at dental practices based in the United States. If you conduct business outside the United States, you should seek appropriate legal counsel in your country of operations regarding consent and refusal within a dental practice.

About the Author

Trey Tepichin is the co-founder and chief executive officer of Cloud Dentistry.

References

1. Dhingra C, Anand R. Consent in dental practice: patient's right to decide. J Oral Hyg Health. 2:129. doi:10.4172/2332-0702.1000129.

2. Kakar H, Singh Gambhir R, Singh S, et al. Informed consent: corner stone in ethical medical and dental practice. J Family Med Prim Care. 2014;3(1):68-71.

3. Harper M. Consent or Refusal: What Every Dental Practice Should Know. DentistryIQ website. https://www.dentistryiq.com/dentistry/oral-systemic-health/article/16354191/consent-or-refusal-what-every-dental-practice-should-know. Published December 19, 2013. Accessed September 15, 2020.

4. Goldsmith C, Slack-Smith L, Davies G. Dentist-patient communication in the multilingual dental setting. Aust Dent J. 2005;50(4):235-241. doi: 10.1111/j.1834-7819.2005.tb00366.x.

5. Notice of Privacy Policy. Serramonte Dental Website. https://serramontedental.com/patient_forms/hipaa_notice_of_privacy_and_consent.php. Accessed September 15, 2020.

6. DuCharme B. Would you make a good dentist? Cloud Dentistry website. https://blog.clouddentistry.com/great-good-dentist. Published August 12, 2020. Accessed September 15, 2020.

7. National Network for Oral Health Access. Dental Forms Library. NNOHA website. https://www.nnoha.org/resources/dental-program-management/dental-forms-library/#consent. Accessed September 15, 2020.