The Proper Documentation Needed for a Dental Malpractice Case

  • Posted on: May 26 2022
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Dentists, like all healthcare professionals, are required to keep records on each patient they treat. Beyond being necessary to treat the patient, this proper documentation is important for use as forensic data and as evidence of legitimate diagnosis and treatment for legal investigations. If you or someone you love has suffered injury due to the negligence of your dentist, such records are also essential to substantiate your dental malpractice case since they will provide evidence of the nature and extent of your injury, and of your dentist’s possible misconduct.

Why You Need Our Strong Dental Malpractice Lawyer

It is sometimes difficult to know whether the harm you suffered is severe enough or sufficiently long-term to make it worth going through the time-consuming and emotionally-wearing process of filing a dental malpractice lawsuit. This is the time to check with a knowledgeable and experienced dental malpractice attorney like Lance Ehrenberg, Esq. of Dental Malpractice Lawyers of New York. 

Mr. Ehrenberg will assess the viability of your dental negligence claim during a free consultation. If you become his client, he will make certain to obtain all pertinent dental records to examine before trial and to use as leverage to establish that your dentist did not live up to normal standards of dental care. 

In addition to being powerful and persuasive in the courtroom, you will find him to be a caring person who will fight vigorously to win you the compensation you deserve. He also knows how crucial it is to have expert testimony by a well-respected dental specialist in the correct disciplinary area and is able to provide you with a strong witness no matter what type of dentistry your case involves.

How Proper Documentation Will Help Your Dental Malpractice Case

Pertinent dental records will help to document the history of your dental problems, your clinical examinations and any diagnostic tests (e.g. X-rays), your diagnosis, the treatments administered or procedures performed, and your prognosis.

According the National Institutes of Health Journal of Forensic Dental Sciences, proper dental documentation should include:

  • Personal identification (name, DOB, contact and emergency contact information
  • Dental history and pertinent medical history (including any systemic disease or bleeding disorder, major accident or serious medical event, relevant family medical history, )
  • Allergies to medication or anesthesia
  • Whether the patient is or may be pregnant
  • Physical and emotional tolerance for procedures
  • Name of patient’s primary care physician
  • Results of clinical examinations and charts
  • Diagnosis of patient’s condition
  • Treatment plan to resolve problems 
  • Documentation of informed consent
  • Smoking, alcohol, and recreational drug history

How Proper Documentation Helps Your Dental Malpractice Case

Getting hold of the dental records kept by your dentist is vital to making a successful case for negligence. Our sharp dental malpractice attorney will examine the records kept by your dentist for evidence that may point to failures, inaccuracies, or even tampering that may bolster our claim.

Among things he will look for are:

  • Incomplete entries, lacking essential detail
  • Merging of dental and financial records which is considered inappropriate
  • Notations of opinions, criticisms, derogatory comments which are also inappropriate, indicating an unprofessional attitude and lack of empathy
  • Absence of a signed informed consent form for any dental procedure
  • Absence of a highly visible sticker on your folder to indicate allergies, your medications, the need for antibiotic pre-medications, and clinical conditions that may affect treatment
  • Illegible entries and/or absence of consistent formatting that often indicate lack of organization, careful recording or concern
  • Corrections shown by erasures or correction fluid which may undermine credibility of the document as a whole

As you can see, the proper documentation may be key evidence of dental negligence. Combined with medical evidence of your injury and the testimony of a dental and/or medical expert, having proper documentation of your dentist’s failings will assist Lance Ehrenberg in his fight to obtain the damages you need and are entitled to receive.

Contact Our Experienced Dental Malpractice Lawyer Today

The sooner you consult with us, the better our chances in court. Contact us now so we can get started working on your case. You will be charged no attorneys’ fees until we recover damages.

Posted in: Dental Malpractice