Dentists can protect themselves from litigation by maintaining clear, complete clinical records that document patient conversations and treatment decisions, building strong patient relationships based on trust and informed consent, and ensuring all notes are legible and properly dated without alterations.
- Complete clinical records should include patient presentation, clinical findings, treatment recommendations, materials used, and next steps -- handwritten notes must be legible or are indefensible.
- Document all patient conversations, including consent discussions, treatment alternatives, risks and benefits, and any declined or deferred recommendations.
- Build patient relationships by explaining expectations, acknowledging unexpected outcomes with empathy, and following up after difficult procedures to increase forgiveness for less-than-optimal results.
- Never alter records. Make dated addendums instead of crossing out or deleting entries.
A few years ago, on the sidelines of my daughter’s soccer game, a fellow parent asked me to help with a legal case involving a dentist. That was the start of my unintended side gig reviewing dental litigation cases.
I enjoy the work because I like helping dentists defend what they do and how they do it. Unfortunately, some cases are not defensible, and not always because the dentist did something wrong. More often, the problem is sloppy or downright poor recordkeeping.
Here are three pieces of advice I would give to any dentist to help keep a complaint against them out of a courtroom.
Keep a complete and clear clinical record.
Dr. Monique M. Nadeau.
This begins with your recordkeeping method. In 2026, I am surprised by how many cases I review that involve handwritten charts. If you use paper, legibility matters. A note that can’t be deciphered is essentially useless, and I can’t defend care that no one can read.
Electronic records have their own pitfalls, including copied-forward notes that make me question what really happened at that visit.
Model your notes on what we were taught in dental school. They don’t need to follow a strict SOAP (subjective, objective, assessment, plan) format, but each encounter should include why the patient is there that day, whether the patient is symptomatic, and the clinical and radiographic findings that led to your treatment recommendation.
Then document what you did, the materials used, and finish the note by indicating whether treatment is complete or what comes next. The radiographs you base decisions on should be of diagnostic quality, and it doesn’t hurt to add some clinical photos as well. Never go back and alter a record by crossing out or deleting an entry. Make a separate note, dated when you write it, as an addendum to a previous entry.
Document your conversations, not just your procedures.
Record conversations you had during the appointment, for example:
- That the patient consented to the treatment that day and that you discussed any alternatives to treatment, as well as the advantages, disadvantages, risks, and benefits of each
- That you discussed bruxism, its contribution to the patient’s broken tooth, and your recommendation for a nightguard
- That the patient declined or deferred the recommended treatment
You never know when a simple conversation will spare you the stress of a lawsuit. This matters most when a patient is not following your advice. If your notes indicate that you did indeed inform the patient, your case is more easily defensible. Similarly, your administrative team should document conversations they have with patients in either the patient’s chart or a communications log.
Build relationships with your patients.
Every patient is a human being who wants to be seen, heard, and understood. Patients who are well informed and who know and trust their dentist are more likely to forgive a less-than-optimal clinical outcome.
Dentists should strive to build relationships with patients by explaining what to expect and possible adverse events, acknowledging unexpected or undesired outcomes promptly and with empathy, and following up after difficult procedures or appointments.
In conclusion, the question I am ultimately asked is whether the treatment and decision-making met the standard of care. I can answer that question with a clear picture of what the patient presented with, a clear picture of the treatment rendered, and a clear understanding of every communication with the patient.
I hope someday to never have another case to review, because all dentists are out there exceeding the standard of care, communicating clearly with their patients, and documenting their cases appropriately.
Dr. Monique M. Nadeau is a general dentist who owns a private practice in Connecticut. She earned her bachelor's degree from Siena University, her Doctor of Medicine in Dentistry degree from the University of Connecticut School of Dental Medicine, and she completed a residency in general dentistry. Nadeau is a member of the ADA, the Connecticut State Dental Association, the Hartford Dental Society, the Academy of General Dentistry, the International Association for Orthodontics, the American Academy of Facial Esthetics, the Alliance of Independent Dentists, and Mommy Dentists in Business.
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