LEGAL ISSUES
TERMINATION OF PATIENT
1. When can I properly terminate a patient?
The most important issue in terminating a patient is timing. The second most important is communication and/or documentation. As with other questions, the Board of Regents Rules provides the guidepost. Unprofessional conduct includes “abandoning or neglecting a patient or client under and in need of immediate professional care, without making reasonable arrangement for the continuation of such care.” A dentist should not terminate a patient in the middle of treatment. Rather, if there is a termination, it should be done at a point in time when there in no immediate follow-up care necessary. If there is temporary work, such as crown preparation or temporary restoration, this is not a normal stopping point. If there is a termination, a dentist should do so in writing indicating to the patient that the dentist/patient relationship is over, the reason for the termination, a statement that the dentist will remain available for a reasonable period of time (30 day is standard) for any dental emergencies. The reasons for the termination should also be noted in the patient’s record.
2. What are proper reasons for terminating a patient?
This question is easier to answer in the reverse. That is, you may terminate a patient for many reasons, however, you may not terminate a patient for a discriminatory reason. For instance, it would be considered discriminatory to terminate a disabled patient because you do not want to accommodate the individual. It is entirely appropriate to terminate patient because the patient fails to pay an outstanding balance, has been difficult with you or with office staff, has threatened a lawsuit, has broken appointments or simply because the dentist wants to reduce the number of his/her patients.
3. Must I wait until a normal stopping point to terminate a patient who has been physically threatening?
If a patient threatens to assault or actually assaults you or a member of your staff, the best thing is to contact the police immediately. You should discharge the patient immediately and make appropriate arrangements for any immediate care that the patient may need. If the patient has not actually crossed this line, but has still created a scene or unreasonably disrupted your office, you will want to make other arrangements to have any immediate dental care handled and terminate the relationship. The important thing is to make it clear to the individual that you will not tolerate such conduct in your office. You should be careful to document the threat or assault and to contact the appropriate authorities.
ABANDONMENT:
§ 29.2 General provisions for health professions.
a. Unprofessional conduct shall also include, in the professions of: acupuncture, athletic training, audiology, certified dental assisting, chiropractic, dental hygiene, dentistry, dietetics/nutrition, licensed practical nursing, massage therapy, medicine, midwifery, occupational therapy, ophthalmic dispensing, optometry, pharmacy, physical therapist assistant, physical therapy, physician assistant, podiatry, psychology, registered professional nursing, respiratory therapy, respiratory therapy technician, social work, specialist assistant, occupational therapy assistant, speech-language pathology, except for cases involving those professions licensed, certified or registered pursuant to the provisions of Article 131 or 131-B of the Education Law in which a statement of charges of professional misconduct was not served on or before July 26, 1991, the effective date of Chapter 606 of the Laws of 1991:
1. abandoning or neglecting a patient or client under and in need of immediate professional care, without making reasonable arrangements for the continuation of such care, or abandoning a professional employment by a group practice, hospital, clinic or other health care facility, without reasonable notice and under circumstances which seriously impair the delivery of professional care to patients or clients;
DISABLED PATIENTS
1. Must a dentist pay for an interpreter for a hearing impaired patient?
The Americans with Disabilities Act applies to all private dental offices as they are viewed as places of public accommodation. As such, a dentist must provide reasonable accommodations to disabled individuals. There are times, therefore, when a dentist may have to pay for the services of an interpreter for a hearing impaired patient to achieve effective communication. The answer will depend on if another reasonable alternative accommodation is satisfactory. For example, many hearing impaired patients may be very good lip-readers or prefer to communicating through written notes. The Americans with Disabilities Act does encourage discussion with the individual as to the accommodation. A dentist may not terminate a hearing impaired patient because s/he does not want to pay for an interpreter.
2. What are the office’s obligations under the American with Disabilities Act?
Existing dental offices must remove barrier to care that exist for disabled patients. Renovated or new offices must be accessible.
CHILDREN AND PARENTS
1. Which parent of a divorced couple has the right to authorize treatment for a minor?
Either parent may authorize and consent to the treatment of a minor. Since it is the child who is receiving the service, the child is legally responsible for the debt, but the parents are also jointly liable for the payment. If there is any questions, let the parents sort it out between themselves.
2. Can I tell a parent that a minor is pregnant?
The personally health information that you learn in your capacity as a dentist is confidential. You should not disclose that information without your patient’s consent. The Public Health Law § 2504 gives a pregnant minor the ability to consent to dental services “relating to prenatal care” and, therefore, there is no need to consult with the parents in order to receive consent.
3. Can I exclude parents from the examination room while I am treating the minor?
There are many times in where the presence of a parent may make it more difficult to perform a procedure on a minor. If in your professional judgment the parent should be excluded from the room you may require that. Obviously, a parent who disagrees has the right to go to another dentist.
EMERGENCY SERVICE
16. I’m going on vacation. Is my answering machine message sufficient?
According to the ADA and NYSDA Code of Ethics (Section 1-D, Emergency Service): Dentists shall be obliged to make reasonable arrangements for the emergency care of their patients. Legally, they must provide a method in which immediate access to dental care is possible.
Leaving a message on a phone answering machine that informs the patient the office is closed and to call back at a later time is not adequate, and can lead to a disgruntled patient or a complaint to the Ethics Committee or, worse, the Office of Professional Discipline.
You can protect yourself and keep your patients confidence by incorporating any of the following in the message on your phone answering machine, or with your answering service, during your absence:
(1) A telephone number at which you can be reached in an emergency.
(2) The name and number of another dentist who has agreed to provide emergency coverage.
Any of the above is not only ethical and legal, but makes for good practice management and good patient relationships.
SUPERVISION
17. Can my hygienist see patients while I’m not in the office?
In New York State, the practice of dental hygiene must be performed under the supervision of a licensed dentist. There are two levels of supervision – personal and general.
Personal supervision means that the dentist is in the dental office or facility, personally diagnoses the condition to be treated, personally authorizes the procedure and, before dismissal of the patient, personally examines the condition after treatment is completed. Dental hygienists may perform the following services under the personal supervision of a licensed dentist only:
• placing or removing rubber dam;
• removing sutures;
• taking impressions for study casts (study casts shall mean only such casts
as will be used for purposes of diagnosis and treatment
planning by the dentist and for the purposes of patient education);
• placing or removing matrix bands;
• applying a topical medication not related to a complete dental
prophylaxis;
• placing and removing periodontal dressings;
• selecting and prefitting provisional crowns;
• selecting and prefitting orthodontic bands;
• removing orthodontic arch wires and ligature ties;
• taking impressions for space maintainers, orthodontic appliances, and occlusal guards;
• placing and removing temporary separating devices
• placing orthodontic ligatures;
• bleaching; and
• procedures within the scope of practice of a NYS licensed certified dental assistant, which are not listed under general supervision.
General supervision means that a supervising dentist is available for consultation, diagnosis and evaluation, has authorized the dental hygienist to perform the services, and exercises that degree of supervision appropriate to the circumstances. General supervision does not mandate that the employing dentist be physically present in the office at all times.
The definition described includes three parameters:
1. A supervising dentist must always be available — this could be another dentist down the hall or across the street who could be quickly summoned. In some situations, a conversation with the supervising dentist may suffice, as long as the supervising dentist could be quickly summoned should the need arise.
2. The treatment rendered by the dental hygienist is authorized in advance (proof of authorization, in the absence of the employer-dentist, should be written somewhere).
3. “.. . exercises that degree of supervision appropriate. . .,“ which means, for example, a patient new to the practice or a patient presenting a difficult management or medical problem should not appear on a day the dentist is not physically present in the office. The relationship between the dentist and the dental hygienist requires that professional judgment be exercised in the above cited examples.
Dental hygienists may perform the following services under the general supervision of a licensed dentist:
• removing calcareous deposits, accretions and stains including scaling and planing of exposed root surfaces indicated for a complete prophylaxis;
• applying topical agents indicated for a complete dental prophylaxis;
• removing excess cement from surfaces of the teeth;
• providing patient education;
• placing and exposing X-ray films;
• performing topical anticariogenic agent applications, including but not limited to topical fluoride applications and performing topical anesthetic applications;
• polishing teeth, including existing restorations;
• taking medical history including the measuring and recording of vital signs;
• charting caries and periodontal conditions as an aid to diagnosis by the dentist;
• applying pit and fissure sealants; and
• applying desensitizing agents to the teeth.
Please remember that under Part 29 of the Rules of the Board of Regents, it is considered unprofessional conduct for a licensee to perform any service that is beyond his or her individual professional competence, even if that service is within his or her scope of practice.