Dental practices should develop protocols for tracking consultations, including patient compliance, and documenting conversations between referring and consulting dentists. In addition, patients’ dental records should reflect referral compliance (or non-compliance) and include related correspondence.
Lack of communication between dentists can result in a delay in diagnosis or treatment, the failure to act upon abnormal test results or findings, the duplication of a prescription or failure to prescribe appropriate medications or order diagnostic testing. A lack of clearly defined roles and responsibilities for all dentists may impede your ability to provide and promote safe and effective patient care.
- Referring dentists should develop a method for determining whether a consultation has been completed and if a written report has been received.
- As a matter of standard office policy, all consultation reports must be reviewed by a dentist, initialed and dated prior to being filed in the patient’s dental record.
- Office follow-up procedures should provide for easy identification of a patient’s noncompliance with the recommendation for a referral, such as when a written report has not been received from the consultant.
- If a patient has been non-compliant in obtaining the recommended referral/consultation, written follow-up with the patient is necessary. Your discussion with the patient should include reinforcement of the necessity and reason for the referral/consultation, as well as documentation in the patient’s dental record of all attempts to contact the patient and obtain compliance.
- If a written report from the consultant is not received in a timely manner, you should contact the consultant to determine whether a written report has been generated.
- Consulting dentists should routinely send written reports to referring dentists in a timely manner. These reports should include: findings; recommendations, including interventions and the delineation of the dentist responsible for treatment; and follow-up of abnormal test results, including incidental findings.
- To promote effective communication, the consultant should contact the referring dentist about any patient who fails to keep an appointment. Dental record documentation should reflect the missed appointment, as well as notification of the referring dentist.
- Telephone conversations between referring and consulting dentists are important when clarification of the contents of a report is necessary. Timely contact must be made when an urgent or emergent clinical finding is identified. These conversations must also be documented in the patient’s dental record.
This “Risk Management Tip” was originally published in the Spring 2015 edition of Dental Dateline, which is available here.