Ethics, Jurisprudence, and Risk Management

DENA 101

Orientation to Dental Assisting

Fall 2002

Ethics: A discipline dealing primarily with moral

duty, conduct, and judgment.

These are standards of behavior which we choose to accept for ourselves – not those imposed by some other authority.

Jurisprudence: The philosophy of law or a system of laws.

Laws are the minimum standards established by the state.

Dental Jurisprudence: The system of law applied to dentistry.

The dentist, and the practice of dentistry are controlled by many laws on the federal, state, and local level.

Risk Management: The steps taken by dentists to prevent a

patient from bringing legal action against them.

As the dentist’s employee, you have an important role in preventing or causing a lawsuit!

Ethics & Jurisprudence Compared

Level #1 – A system of law established by society. These represent a minimal standard of acceptable conduct.

Level #2 – A professional code of ethics. These are a statement of conduct the professional organization has accepted.

Level #3 – A personal code of ethics. These represent the highest standard of acceptable conduct.

Conduct may be unethical and still be legal. But it cannot be illegal and still be ethical.

Professional Ethics: Consistently higher than the standards

required by law. Voluntary controls, however, everyone

entering into the profession is expected to adhere to these professional standards.

Serve as a method of self-policing, and enforcement of the code is handled within the professional organization.

Personal Ethics: Standards which individuals set for

themselves. These are our own “inner rules” for acting

responsibly. These standards are reflected in the way we

act, the decisions we make and the values we hold.

A Decision is Ethical if: 1- It enhances integrity and self-respect. 2 – It does not bring harm to others. 3 – It builds understanding and dissolves

unreal barriers between people. 4 – It builds a core of genuine confidence

in self and others.

A Decision is Not Ethical if: 1 – It results in an illegal action. 2 – It brings harm to others. 3 – A person is exploited and used as an

inhuman object. 4 – If human potential is belittled,

damaged, or ignored.

One of your primary responsibilities is to treat the dentist(s), staff members, and all patients with dignity and respect.

The philosophy of individual worth is the belief that everyone, regardless of personal circumstances or personal qualities, has worth and is entitled to respect as a human being.

Law: A set of rules established and enforced by a

sovereign authority such as the local, state, or federal government as a means to an ordered society.

Criminal Law pertains when a person commits a wrongful act against society.

Civil Law pertains when one person sues another for satisfaction of a personal wrong done to him or her.

Plaintiff (accuser) is a person bringing the legal action which accuses another of wrongdoing.

Defendant (accused) is a person whom legal action is being brought against.

Reasonable (Prudent) Person A reasonable person is expected to do

those things that are appropriate in a given situation.

This includes the use of sound judgment, so that these actions are fair, proper, just, moderate, and suitable under the circumstances.

Negligence – failing to do something that a reasonable person would do, or doing something that a reasonable person would not do.

Contributory negligence – failure on the part of the patient to follow the dentist’s instructions during and after treatment.

Malpractice – professional negligence. Failure to perform one’s professional duties completely.

Admission against interest – statement made by an individual which serves to defeat his or her own interests. “Oh, I’m sorry. It was my fault.”

Res gestae – Latin term meaning “Things done or part of the action” Statements made spontaneously at the time of the alleged negligent act are admissible as evidence.

A careless word or statement by an auxiliary can be just as damaging to the dentist as his or her own admission against interest.

What to Do of the Dentist is Sued1. Say Nothing

2. Be supportive

3. Be cooperative

4. Ask before acting

State Dental Practice Act Controls the practice of dentistry only

within that state. The primary purpose of the State Dental

Practice Act is to protect the public from being mistreated or misled be incompetent practitioners.

Provisions of the State Dental Practice Act1. Eligibility for licensure.

2. The methods and requirements for licensure.

3. A definition of what is included in the practice of dentistry within the state.

Provisions of the State Dental Practice Act Grounds for suspension or revocation of a

license. Provisions for establishing and maintaining

an administrative board to supervise the practice of dentistry.

A means of controlling the assignment of duties, including extended functions, to auxiliaries.

Grounds for suspension or revocation of a license.

Provisions for establishing and maintaining an administrative board to supervise the practice of dentistry.

A means of controlling the assignment of duties, including extended functions, to auxiliaries.

State Board of Dentistry Also known as the State Board of Dental

Examiners. Primary functions include:

Examine applicants and grant licenses.

Deal with misconduct, incompetence, and related matters.

Establish and regulate the functions assigned to other related professionals in dentistry.

ReciprocityA mutual agreement between two or more states to allow an individual who is licensed in one state to receive, without further examination, a license in the other state entering into that reciprocity agreement.

Grounds for Suspension or Revocation Conviction of a Crime

Unprofessional Conduct

Personal or Professional Incapacity

Specific Grounds for Discipline Permitting unlicensed personnel to perform

dental procedures normally restricted to dentists. Failure to supervise personnel properly. Sexual advances toward or involvement with

patients. False or inaccurate patient records Fraud involving reimbursement of patient

expenses by insurance companies of government programs.

Giving or receiving rebates related to patient fees. Transmission of disease by improper sterilization

procedures. Improper communication of confidential patient

information. Improperly prescribing, handling, or selling

controlled substances. Patient neglect or abandonment.

Respondeat superior “Let the master answer”

In addition to being held responsible for his or her own acts, under the doctrine of respondeat superior, the dentist/employer is also held responsible for the acts of his or her employees – if that wrongdoing was committed within the scope of their employment.

Who may be sued?A dental assistant who is guilty of negligence is responsible for his or her own actions, and the injured party may sue both the dentist and the assistant.

The dentist’s liability insurance will not cover the auxiliary if they are sued for negligence!!

Levels of Supervision Direct supervision – a licensed dentist is present

in the room. Indirect supervision – a licensed dentist is

present in the office. General supervision – under the direction of a

licensed dentist though not present in the office. Undefined supervision – under the direction of a

licensed dentist, but supervision id not defined.

Civil Law Contract Law – division of civil law

covering specific agreements between people and violations of same.

Tort Law – division of civil law covering the rights and duties of people toward each other and wrongs committed in violation of these rights and duties.

Contract Law Those entering the agreement must be

legally competent. The act covered by the agreement must be

a lawful one. There must be a consideration involved in

the contract.

Types of Contracts Implied – A contract is made by certain

actions on the part of the parties concerned, even though the essentials for a legally binding contract have not be discussed.

Expressed – A contract in which there is oral or written agreement as to the terms of the contract.

When Written Consent is Required: New drugs are being used Experimentation or clinical testing is involved A patient’s photograph is being used General anesthesia is being used Minor children are being treated in a public

program Treatment will require more than one year to

complete

Breach of Contract

Breach of contract occurs if either party fails to keep their part of an expressed contract, either written or oral. When this happens the other party may sue for breach of contract.

Four “D’s” of Tort Law Duty – a legal duty must be owed by someone to

another Dereliction – the duty owed must have been

breached by the accused Damage – the plaintiff must have been hurt in

some way Due to – the plaintiff must be able to prove that

the defendant’s action, or lack of, were the proximate cause of the damage

Establishing a Legal Duty

A dentist-patient relationship (legal duty) does not exist in law until the patient seeks service from the dentist, and the dentist, by some words or action, accepts the patient.

Patient of Record A patient of record is someone the dentist

has already accepted as a patient.

The dentist is not legally compelled to accept or treat a new patient just because an emergency exists, however, the dentist is obligated to provide emergency treatment for a patient of record.

Liabilities in DentistryThe dentist may be held liable in the following ways:

1. Breach of contract

2. Maligning a patient

3. Permitting a hazard in the dental office

4. Technical assault

5. Malpractice

Malpractice1. Professional misconduct

2. Any unreasonable lack of skill

3. Lack of fidelity (faithfulness) in performance of professional duties

4. Practice contrary to established rules

Malpractice May Be Do To:1. Ignorance or neglect

2. Lack of skill

3. Neglect in applying these skills

Dentist’s Responsibilities to the Patient Must be properly licensed Must exercise reasonable skill, care, and

judgment Must do only those things consented to by

the patient Must refer unusual cases to a specialist Must use standard drugs, materials, and

techniques

Must complete agreed upon treatment within a reasonable time

Must hold inviolate the patient’s privacy Must give adequate instructions to the

patient. Must make a reasonable charge for the

services rendered

Patient’s Responsibilities to the Dentist Must follow instructions during and after

treatment Must pay a reasonable fee or a fee agreed

upon between dentist and patient

Withdrawal from a Case or Patient Written notification – containing the reason, the

withdrawal date, the need for further care, an offer of help or assistance, and signature.

Proof of mailing – letter must be sent certified mail with a return receipt requested.

Documentation on file – a copy of the letter and the signed postal receipt are kept with the patient’s record.

“Happy patients don’t sue

their doctors.”

Ten Rules of Risk Management When in doubt say nothing If there is a problem or conflict with a patient,

refer the matter to the doctor Never say anything that implies a guarantee or

that will give the patient unrealistic expectations as to the result which the dentist can achieve

Never comment on the quality of care provided by your employer or any other dentist

Establish a rapport with the patients Maintain accurate, complete and legible

records (they are the dentist’s best defense!)

Keep all of your skills up-to-date Always perform all of your duties to the

best of your ability

Be prepared to assist in any kind of emergency

Do not start collection measures without the doctor’s permission

Patient RecordsThe patient’s dental record, commonly referred to as “the chart”, provides a chronological record of, the clinical justification for, treatment received by the patient.

These records are important legal documents.

Part of the Patient’s Clinical Record Medical and dental histories Examination findings and treatment plans X-rays (properly identified and dated) Any letters from, or about, the patient regarding

treatment Copies of prescriptions Written consent or refusal of treatment forms Notation of broken appointments or any failure to

follow the treatment or advise of the dentist

Not Part of the Patient’s Clinical Record Any records that are kept for financial

reasons only Financial information such as the record of

charges, payments and the current balance Insurance claim forms Irrelevant materials, such as post cards

from the patient

Guidelines For Clinical Record Entries Use the next available line Make the entry as soon as possible after the

patient’s visit Date the entry Sign or initial the entry to clearly identify who

made the entry Make the entry clear, concise, and complete The entry must be typed or in ink (blue or black) Handwritten entries must be legible

Changes to the Clinical Record Never change a chart entry without the doctor’s

permission; however, an error should be corrected as soon as possible after it is discovered

Draw a single line through incorrect material. The original entry must still remain readable.

Add your initials (to show who made the correction) and the date (to show when the correction was made)

On the next available line, explain the reason for the change. Initial and date this entry.

On the following line, enter the correct data. Initial and date this entry.

Five Rules for Safeguarding Patient Records Do not allow any unauthorized person to

remove, read copy, or otherwise tamper with any record at any time.

Never leave an open file folder on your desk when an unauthorized person could read it

Always lock file cabinets and/or rooms containing files at the end of the day

Refrain from answering queries regarding patients from third parties such as a lawyer. Refer all third party inquiries to the doctor

Do not allow original patient charts to leave the practice.

The patient chart is created by the dentist for his or her own use. Under law, these records are considered to be the dentist’s property. What the patient pays for is the dentist’s professional skill in interpreting these records

Professionalism No matter what your relationship with the

doctor, always address him or her as “doctor”

Adult patients are always addresses using the more formal, courteous form of address such as Mr., Mrs., or Ms.

Always introduce yourself to someone new