When a treatment is questioned months or years later, the dentist’s memory counts for little. What counts is the file. The case history, the consent form and the treatment notes are, in practice, a dentist’s best defence, and the patient’s best protection.
The case history
A good history is clinical care first and legal protection second. It should record the chief complaint in the patient’s own words, the medical history, current medicines, allergies, past dental treatment and habits such as tobacco. Conditions like diabetes, heart disease, bleeding disorders and pregnancy change what is safe to do, and the file should show that the dentist knew about them before starting.
Informed consent
Consent is not a signature; it is a conversation that the signature records. The patient should understand what is proposed, why, the material risks, the alternatives including no treatment, and the likely cost. For surgical procedures, implants and extractions, written consent is the norm. For a child, consent comes from a parent or guardian.
Treatment records
- Date every entry and write it on the day of treatment.
- Record what was done, the materials used and any complications, however minor.
- Keep radiographs, photographs, laboratory slips and prescriptions with the file.
- Note missed appointments and advice the patient declined.
- Never alter an old entry. If a correction is needed, add a dated note.
Why it matters
In a negligence complaint the burden of proof often turns on documents. A clear file shows that the dentist assessed the patient, explained the options, obtained consent and acted with reasonable care. A missing or careless file suggests the opposite, even when the treatment itself was sound. Good records cost a few minutes per patient. Their absence can cost a career.