Records adulteration

by Dianne Glasscoe Watterson, RDH, BS, MBA
[email protected]

Dear Dianne,
A few months ago, the doctor saw one of our regular patients for a toothache. He wondered why I had missed the “huge hole” on No. 13, as I see the patient for cleanings regularly. I was dumbfounded. I have proven to him to be meticulous with finding even the smallest areas of decay, and if the doctor is not in the office when I see patients, they are always scheduled for yearly exams. I didn’t understand what happened. The patient ended up getting a root canal and crown.

About three weeks ago, the patient came in for her regular cleaning. When I opened the chart, all my notes from the past two years were no longer there. They had been replaced with notes the office manager had written and then forged my name and title behind them!

I took a deep breath and continued with my patient like nothing was wrong. She happened to be my last patient of the day. Neither the doctor nor the office manager, who also happens to be the dentist’s wife, was in the office that day, so I called and spoke with the doctor, who was home on medical leave. He said when he returned, the three of us would discuss this. So far, nothing has been discussed.

Here’s what I believe happened. The doctor or office manager was not in the office when I saw the patient, and the patient was asked to return for an exam. The office manager failed to contact the patient to have her return for the exam. I believe the reason she rewrote everything is because I noted the decay and the patient needed to return. Our office protocol is that the office manager is supposed to call the patient and schedule her. Obviously, she failed to follow up.

I called the state board. The contact person there said that since the office manager is not a licensed professional, they cannot take action against her. They recommended I speak with the doctor and try to resolve the issue or file a complaint against him.

Today, I spoke with a local attorney who acted like this was no big deal and looked at me like I was a little crazy. Basically, he said I should not go after the doctor, because it will make it very difficult for me to ever get a job again. He said I should request that the doctor provide me with a positive letter of recommendation and not retaliate for seeking new employment.

Quite honestly, it’s not the doctor I’m worried about. It’s his wife. She has a long history of retaliation and making the working environment unpleasant. Unfortunately, finding a new job has proven to be very difficult during these times.

I truly feel as if I’m stuck in this office for the time being, and I’m afraid of making matters worse for myself by continuing to ask the doctor to address this issue with his wife. What should I do?
California RDH

Dear California,
This is one of the most egregious acts of records adulteration I have ever encountered! It is a serious legal issue. When I taught in a hygiene school, records adulteration was one infraction that could cause a student to be dismissed from the program.

Records adulteration is one of the major reasons that dentists lose malpractice cases. I know of an oral surgeon who, when he found out he was being sued, tried to add to his chart notes. The courts used ink dating technology to prove the notes were not contemporaneous. His credibility was destroyed, and he lost the case.

In your case, the courts would have no trouble proving the forged signature is not your own. Current record evaluation methods include ink analysis, light reflection tests, transmission analysis, and computerized handwriting analysis. I expect you would have an open and shut case for forgery against the office manager.

Do you think the wife did this with her husband’s blessing? It seems obvious that she is ignorant of the serious potential consequences of her actions. In trying to cover their negligence, she made the situation far worse. She has committed two illegal acts — records adulteration and forgery.

What to do? Let’s consider your options. If you file a complaint against the doctor with the dental board, you create an atmosphere of hostility and your job is toast. I expect you would not want to be there. While retaliatory firing is illegal, consider the negative workplace atmosphere that would result. The doctor is ultimately responsible for the acts of omission and commission from employees.

Undoubtedly, the dental board would take the office manager’s actions very seriously. Any punitive action by the dental board would have long-lasting consequences for the doctor. There would be an investigation, the patient would have to be examined by an outside consultant, and the patient would have full knowledge of the situation.

While it is clear the record was altered, it would be your word against the doctor’s word. They might try to make up some excuse as to why the record was rewritten, such as “I spilled coffee on it and ruined it,” or some other garbage.

You could file a lawsuit against the office manager regarding the forgery. Are you prepared for legal fees and the hassle of a lawsuit? I expect this could only make matters worse.

Everybody makes mistakes, and with all that goes on at the front desk, it would have been easy to forget to call the patient to come back for a timely examination. The patient was not irreparably damaged, although she did have to endure endo and crown procedures. Even with a timely exam, the patient might still have needed those procedures. Sometimes the decay is much deeper than it appears on an X-ray, and I expect with the time frame of just a few weeks or months between her prophy and the toothache, the decay was probably either dangerously near or already into the pulp.

Consider the consequences of forcing dialogue about the situation with the doctor. Your knowledge of records adulteration and forgery puts you in a position of power, and he may feel threatened by you. The concept of “respondeat superior” is a Latin phrase that literally means, “let the master answer.” So although it was his wife who committed the illegal acts, he is ultimately responsible. Again, this has the potential of creating a hostile work environment. Everybody has a self-preservation mode.

Please don’t misunderstand though. Nothing — and I do mean nothing — excuses the wife’s forgery of your name and records adulteration. You have every right to feel angry, disrespected, and threatened. I have no doubt that the doctor would feel the same negative emotions if someone forged his name to chart notes he did not write.

I think it goes without saying that you need to leave that practice as soon as you can secure other employment. You may feel stuck at the moment, but if you are like most people, you need to pay your bills and survive.

Be sure you have carefully documented those conversations and dates with the state board and the attorney, just in case this thing bubbles to the surface again. The only negative thing I can think of would be if the patient would decide to sue the doctor for malpractice. The doctor could decide to try to implicate you, but again, he is ultimately responsible. You can prove through handwriting experts that the notes are not your own handwriting.

You have to weigh all the options. Sometimes taking definitive action makes things worse. My own self-preservation trumps any satisfaction I may receive from bringing someone down, especially if such actions hurt my family and me.
Best wishes,
Dianne

Dianne Glasscoe Watterson, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe Watterson for speaking or consulting, call (301) 874-5240 or email [email protected]. Visit her website at www.professionaldentalmgmt.com.