A reader from Connecticut wrote with the following questions.

A parent calls last minute to reschedule their child’s after school appointment, demands to be seen at the same time on a following day, and uses rather unprofessional language while speaking to one of my scheduling coordinators when she learns that she can’t have what she wants. How exactly should this encounter be documented? I mean, should my scheduling coordinator accurately document what the mother said (including the inflammatory and expletive words) as well as what her response was? Should this be paraphrased, leaving out the unprofessional language? Alternatively, should the scheduling coordinator document the unpleasant encounter using her own suitably professional language in summary form in the patient chart (I use digital records) and then refer the reader to another document that is not connected to the treatment notes and that accurately restates the conversation word for word in the exact language used? Any advice you can offer would be helpful. Thanks, J. O.

At times, because of the demeanor of some people in certain situations, we might ponder whether some of our patients were raised by wolves. From what I hear from many colleagues, demanding patients are becoming more common, and having to deal with these people is becoming more of a challenge, thus making our reader’s questions timely. Although our reader did not tell me the actual language used (shucks!), the questions are clear enough to be able to provide some guidance to him and others who have suffered through similar fates.

There are only 2 reasons to document this type of patient behavior. The first is to use it for ammunition if you decide to terminate the doctor-patient relationship. The second is to use the patient’s words to portray him or her as not deserving the sympathy of a jury if that patient initiates a lawsuit against you. The second reason is obvious: people with nasty mouths are often perceived as nasty people, and jurors will not be inclined to be sympathetic toward a nasty plaintiff. That being said, let’s concentrate on the first reason.

Okay, based in the incident as noted above, the doctor decides that he has had enough, his staff shouldn’t have to put up with patients who behave this way, and he wants to dismiss this patient from his practice, thus terminating the doctor-patient relationship. Let’s take a quick look at this relationship. The doctor-patient relationship is consensual. That means that patients are free to seek your services, and they are also free, if they later decide that the relationship is not working out for any number of reasons, to leave and find another doctor for their ministrations. Likewise, doctors can accept or reject someone as a patient, as long as the basis for rejection is not that the patient is a member of a legally protected class of people (race, religion, sex, sexual orientation, national origin, handicapping condition, and so on). In reality, even though our offices are considered places of public accommodation, one court noted that “Doctors are not in the same category as innkeepers or common carriers and need not open their doors to all who seek their services.” (cit. omit.)

Doctors are also free to dismiss patients from their practice, if the patient has breached any of the 5 legally recognized duties or obligations owed to the doctor under the umbrella of the doctor-patient relationship; however, certain procedural protocols must be followed. You are permitted to legally discriminate regarding (1) the provision of services based on such criteria as limiting one’s practice to a particular specialty; (2) the patient’s inability to assume the financial obligations associated with treatment; (3) your not agreeing with the patient’s treatment demands; (4) the patient’s inability to abide by reasonable office protocols, rules, and regulations; and (5) other reasons. This holds true even when the person is a member of a protected class, because the basis for the discrimination applies to everyone evenhandedly; however, the onus to prove that one engaged in a legal form of discrimination rests with the dentist. Another court stated: “The consensual relationship between doctor and patient is based on two jurally recognized expectations. On one hand the patient hopes and expects to be cured; while on the other hand, the doctor hopes and expects to be paid.” (cit. omit.)

The following is a list of the 5 legally recognized duties or obligations that all patients owe us because they agreed to participate in the doctor-patient relationship: (1) all instructions will be followed, such as wearing elastics, headgear, diet control, oral hygiene, and so on; (2) appointments will be kept; (3) fees for services will be paid; (4) they will be truthful regarding their health history, administrative inquiries, protected health information, and so on; and (5) they will conform to generally accepted modes of behavior.

To unilaterally terminate a patient from your practice and not run the risk of being found to have abandoned the patient, the following protocol should be used. First, the patient must be given sufficient notice of the doctor’s intent to withdraw as the practitioner of record. A letter to this effect should be sent both by certified mail, return receipt requested, and by regular mail with a certificate of mailing, because using both methods ensures either that the patient was notified or that a valid attempt to do so was made.

Second, this letter should inform the patient of the reason—the legal basis—upon which you are choosing to terminate the professional relationship. Returning to our contractual analogy, the legally accepted reasons for unilateral termination by the doctor are based on the premise that the patient breached at least 1 of the 5 obligations they owed to you.

If the patient is at a point in treatment that continued care is still required, he or she should be strongly urged to seek it at soon as possible. Admonish the patient that unsupervised orthodontics can lead to many negative sequelae and state a few of the more obvious ones. Inform the patient or parent that you stand willing to give him or her both adequate time and assistance, if necessary, to seek substitute or alternative care. Give the patient a specific time frame during which this needs to occur, such as 30 or 45 days, depending on the geographic area in question and its professional demographic makeup. Inform the patient that, if this cannot be accomplished within the stated time frame, you are advising the removal of all active mechanics or the appliances themselves. Finally, you should note that, during this time period, you will be available only for emergency care, consultation, or a referral, if necessary.

On the other hand, you can never withdraw from offering professional services to a patient who is in extremis. A working definition of extremis is a patient of record who is suffering from significant swelling, is bleeding profusely, is complaining of excruciating pain, or has other exigent conditions that require professional attention. In this case, you must deal with the emergent problem, stabilize the patient, and then proceed with the dismissal protocol.

Finally, inform patients in the dismissal letter that, upon written request, a copy of their records will be sent to them or to a subsequent treating practitioner. Although you might legally be entitled to charge patients a reasonable fee for the duplication of their records, make sure that you do not violate any specific state statutes related to this matter. A good rule of thumb is that the fee for copying x-rays, models, and so on should not exceed the original cost of each record. From a pragmatic perspective, it is important to appreciate that, when unilaterally attempting to terminate the doctor-patient relationship, it might not be prudent to place a financial stumbling block, such as a records-duplication fee, in the patient’s way. Although patients might reticently accept dismissal from your practice because of their actions or inactions, attempting to collect a fee for records duplication could be a sufficient impetus for them to consider retaliatory litigation for any perceived wrong, which, up to this point, was not that important.

This brings us to a tangential factor relating to what should or should not be said or done when a potential subsequent treating practitioner contacts your office to learn why the patient sought a new doctor. Neither you nor your staff should bad-mouth patients regarding such matters as their financial status with your office, their behavior as patients, their level of cooperation, and so on. In other words, you don’t want to say negative things about a patient, even if truthful, because these facts might interfere with his or her ability to secure substitute professional care. All that needs be said is that there were administrative differences between you and the patient, sans the details. We are all smart enough to know what that means.

This now brings us to the initial question regarding how all of this should be documented in the patient’s records. It should now be obvious that, if you ever plan to unilaterally terminate a patient from your practice for any of the 5 accepted reasons, you need to document all instances relating to the breach of the responsibilities owed to you.

Our situation dealt with behavior that was abusive or disruptive to the staff or others in the office. I recommend that you document the event leading to your decision, using the actual conversation. Make sure the discourse reflects what was said by your staff as well as what was said by the patient. Remember, you are stockpiling ammunition to use if your actions are questioned in a lawsuit or an administrative inquiry against you relating to a claim of patient abandonment.

As to where to place this information, ask yourself 2 questions: what is the purpose of and what are the components of the patient’s records? The entire record comprises (1) administrative data such as names, addresses, birthdates, Social Security numbers, parent’s or patient’s place of employment, insurance information, financial contracts, and so on; (2) all your diagnostic information, models, photos, radiographs, and so on; (3) all communications with the patient and other professionals who have treated, are treating, or will treat the patient, such as informed consent, instructions, reports, referral slips, and the like. Finally, we have the patient’s clinical record that includes history, examination, treatment plan, treatment chart, recommendations, and so on, and there is always a section called “other.” Obviously, some sections might overlap, but, for the most part, they are separate and distinct entities of a patient’s comprehensive orthodontic record.

Documenting the occurrence leading to the removal of the patient from your roster of active patients is an administrative decision, one which is often far more subjective than objective, is not clinical, and therefore should not be placed in the clinical chart portion of the patient’s record. Many risk managers advise keeping a separate log that can be incorporated by reference, meaning that this separate log’s entry date will relate to the date of the patient’s visit when the event occurred. Whether you are using paper or digital records, there should be a place for inclusion of this separate component of the patient’s record. On the clinical portion, all that needs to be said is that, because of administrative differences, a decision was made to terminate the doctor-patient relationship.