Compromised patient health warrants medical clearance

By TDIC Risk Management Staff

Dental offices routinely send medical clearance forms to physicians before beginning treatment on medically compromised patients, and The Dentists Insurance Company receives a number of questions on its Advice Line about this practice.

When it comes to medical clearance, the big issue is whether dental treatment could substantially affect a patient’s physical condition or the reverse, whether a physical condition could affect dental care, said Steven Barrabee, a San Francisco-area attorney working with TDIC who specializes in professional liability and business law. “It’s a judgment call dentists must make, and it’s best to err on the side of seeking the medical guidance of a patient’s health care provider.”

To understand their patients’ medical conditions, dentists must ensure each patient’s health history is detailed and current. This crucial step alerts dentists to diseases, disorders, allergies and medications that could affect dental treatment.

“Know all of the medications a patient is taking,” Barrabee said. “This is essential to avoiding adverse interactions.” He said patients with complicated medical conditions such as cancer may not even be sure of all the medications they are taking, but he advised dentists to seek clarification. “I know it’s difficult because doctors are busy, but it’s incumbent upon dentists to ensure their treatment will not adversely affect the patient.”

Barrabee also advised paying special attention to the American Heart Association’s updated guidelines for antibiotic prophylaxis and to patients taking bisphosphonates for treatment of osteoporosis and other bone diseases.

“There can be huge issues with medications, and I have seen a number of cases related to this,” Barrabee said.

When requesting medical clearance from a patient’s physician, TDIC recommends that dentists describe the dental treatment plan and include all prescription and over-the-counter medications that could be used during treatment. Also, indicate why the patient’s condition warrants special concerns. TDIC provides fax transmission forms for medical clearance on its website at thedentists.com. Risk management experts recommend that medical clearance forms include an area for physicians to comment on the patient’s overall health, which alerts dentists to potential issues.

In cases where the patient’s health is severely compromised, a conversation with the treating physician is recommended before beginning dental treatment or prescribing medication of any kind. However, a conversation with the physician is not a substitute for a signed medical clearance form.

“Medical clearance in writing is necessary to provide clear documentation,” Barrabee said.

A medical clearance form signed by a nurse practitioner rather than a physician is generally acceptable, according to TDIC risk management analysts. Nurse practitioners are registered nurses with advanced training in diagnosing and treating illnesses. Among other things, nurse practitioners can obtain medical histories, perform medical examinations, identify, treat and manage chronic diseases, order and interpret diagnostic tests, prescribe medications and refer patients to other health care providers. The scope of allowable duties may vary from state to state.

For more information, contact the American Association of Nurse Practitioners at aanp.org.

If dentists have any questions about the qualifications of the personnel signing the medical clearance form, they should call the physician for verification. Barrabee specified that nurse practitioners or physician assistants can only sign off on what is within their scope of practice.

“If in doubt, follow up,” Barrabee said.

For questions regarding the information presented in this article or if you need to discuss another risk management issue affecting your practice, please call the TDIC Risk Management Advice Line at 800.733.0634.

Topics: Protection, TDIC