Ask the Pro: Dentist deletes hygienist’s clinical notes and denies SRP

Question: I’ve been a clinical hygienist for 13 years, and I’ve been working in a new office for about one year. I recently had a patient who upon clinical periodontal assessment had 2 mm to 6 mm pockets with bleeding on every site. The patient was a smoker.

I shared my findings with the dentist and recommended SRP. After reviewing the x-rays, the dentist advised there was not enough bone loss for insurance to cover SRP. I was shocked and recommended we preauthorize the treatment. There was visual bone loss on x-rays and clinical charts were reflective of current disease. The dentist told me I should perform a 1110 on one arch and then have the patient return for another 1110 on the opposite arch later.

I documented my findings and my clinical opinion in the notes. I disputed the 1110 recommendation and stated that the patient qualified for SRP. When the patient returned for the second appointment, I opened my notes, and the dentist had completely deleted my notes about my assessment and SRP recommendation! I reprobed the lower arch before starting treatment on the upper arch. The patient now had a 7 mm pocket that was previously 6 mm.

There are two major concerns in this scenario: deleting notes done by the hygienist that has my provider's name and number attached, and this patient has deep pocketing/bone loss and is being neglected. 

I feel like my hands are tied. I’ve never in all my years had this type of thing happen. The practice where I worked previously always backed me and my knowledge.

Answer from Sarah Crow, RDH: First, I want to acknowledge how upsetting and frustrating this situation must feel for you. After 13 years of clinical practice, you’ve clearly built a strong foundation of knowledge and patient care experience. To be placed in a position where your clinical judgment is not respected, and worse, where your legal documentation has been altered, is rightfully concerning at the highest level.

2 key issues I want to discuss

Patient care

This patient presented with generalized bleeding, multiple 2 mm to 6 mm pockets, smoking as a risk factor, and visible bone loss. These findings clearly meet the clinical criteria for periodontal therapy. To delay or withhold that treatment compromises not only the patient’s oral health, but their overall health as well.

Ignoring needed treatment also accelerates disease progression, as you already saw with the probing depths worsening from 6 mm to 7 mm on the following visit. While insurance coverage is sometimes used as a rationale for treatment planning, it should never dictate the standard of care and our recommendations as dental providers. Ethical providers recommend what the patient needs first and then work with them on financial solutions.

Documentation and legal implications

Your clinical notes are part of the patient’s permanent legal record and are directly tied to your dental hygiene license. For another provider to delete or alter your notes is simply unacceptable. Not only is this unethical, but it can also be considered fraud or record tampering.

If a patient ever filed a complaint or lawsuit and records had been changed, the liability would be on both the practice and each licensed provider involved. You were absolutely correct to document your findings, your recommendation for SRP, and your disagreement with the dentist. That documentation is both your professional responsibility and your protection.

Here's what I recommend

Continue to write thorough, objective notes at every visit. Be sure to sign your clinical notes. If possible, keep a separate record of any altered documentation for your own protection.

Address it with your office manager. Consider requesting a meeting with the dentist and office manager to clarify how treatment decisions are being made and to discuss documentation policies and request calibration meetings for future case presentations.

Seek external help. Contact your state board to learn how best to proceed. They can provide clarity on your legal responsibilities and next steps if this pattern continues.

Reflect on your environment. If you are consistently prevented from practicing ethically and within the standard of care, it may be worth considering whether this office is the right fit for you long-term. Like Mel Robbins (NYT author, podcast host, and lawyer) says, “If it drains you, delays you, or disrespects you … let it go”

You are right to be concerned, and you are not overreacting. What you are describing is not just a difference of clinical opinion, it is an issue of supervised neglect. By standing firm, you are protecting your patient, your license, and ultimately, the integrity of the dental hygiene profession.

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