Panel hearing summary 2011.0039

Decision of the Dental Board of Australia

Performance and Professional Standards Panel

Jurisdiction: Victoria

Date of hearing and decision: 5 December 2011

Classification of Notification:

Clinical Care - Inadequate or inappropriate treatment

Documentation - Health record - inadequate or inaccurate or misleading

The patient first presented to the practitioner in 1979 with broken teeth, restorations and evidence of periodontal disease. The practitioner did not record the advice he gave to the patient that she be referred to a periodontist, and the patient’s refusal of this advice. Over a period of 30 years, the patient presented to the practitioner for ongoing restorative care, root canals and restorations and advice on oral hygiene.

Allegations

The practitioner faced allegations that he had failed to adequately diagnose and treat the periodontal disease and that the clinical notes did not contain information as required in the Board’s Dental guidelines on dental records.

Finding

The Panel found that

1. the practitioner did diagnose periodontal disease and had many discussions with the patient about oral hygiene and seeking treatment which for various reasons, the patient did not follow and
2. from 19 June 2008 to late December 2009, the practitioner’s clinical notes for the patient did not contain documented consent for treatment, treatment plans, periodontal charting, details documenting the presenting complaint, relevant history, clinical observations or a diagnosis.
3. As a result, the Panel concluded that the first allegation was not made out. In relation to the second allegation, the practitioner behaved in a way that constituted unsatisfactory professional performance in relation to record keeping.

On the basis of those findings, the Panel decided that the practitioner engaged in unsatisfactory professional performance, in that the knowledge, skill or judgment possessed, or the care exercised by the practitioner was below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

Determination

The Panel cautioned the practitioner to ensure that in the future all dental records complied with all statutory requirements and all requirements outlined in the Board’s Dental guidelines on dental records.

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