By: Roger Berger
Short answer: Texas law requires it, so your dentist is conscientious regarding the rules.
The Texas Administrative Code sets forth requirements for dentists and their dental records. Among the requirements (taking and documenting) are vital signs, including, but not limited to, blood pressure and heart rate. 22 TAC §108.8(b)(4).
This provision refers the dentist to 22 TAC § 108.7, which sets forth the “standard of care” for dentists.[1] This section of the Code does not specifically address vital signs but does include a provision requiring dentists to “perform and review a limited physical examination when a reasonable and prudent dentist would do so under the same or similar circumstances. At a minimum, a limited physical examination should be performed and reviewed annually.” 22 TAC § 108.7(4).
In my experience before the Texas State Board of Dental Examiners (the Board), this provision does require that vital signs be taken and recorded, though the required frequency of doing so can be flexible. A dentist should endeavor to take and record vital signs at least once a year; but, the dentist needs to be attuned to other issues such as changes to medical history (addressed further below), because those other issues may require more frequent checking and recording of vital signs if a “reasonable and prudent dentist would do so.” This gives some flexibility to the licensee but also gives the Board the ability to substitute their clinical judgment (as we often see from expert reviewers or panelists at Informal Settlement Conferences (ISCs)).
What do “reasonable and prudent” dentists actually do in terms of taking and records vital signs? I did an informal and admittedly unscientific survey for this article, asking all employees of the firm and current and prior clients about their practices. How better to determine what a “reasonable and prudent” dentist does? Two-thirds of the respondents said that their dentist takes their blood pressure at every visit, 15% said their dentist never has taken their blood pressure, and a few said their dentist checked blood pressure at the first visit but never again.
I also surveyed what other dentists are doing with respect to obtaining and updating medical history, since it is a related issue and one that would give a reasonable and prudent dentist a reason to check and record vital signs. The Board requires that a dentist “obtain, maintain, and review an initial medical history” and review the medical history with the patient “any time a reasonable and prudent dentist” would; but, at a minimum, the medical history should be reviewed and updated annually. 22 TAC § 108.7(3). My survey revealed that 30% of dentists obtain an updated history at each visit, 30% never asked for an updated history, 15% update it yearly, and 15% never formally update the medical history but ask verbally for any updates.
I also included two aspects of informed consent in my survey since I have run into these issues in Board Investigations. Dental records must contain written informed consent. 22 TAC § 108.8(c)(8). This section refers dentists to the provisions of section 108.7(7), which requires dentists to:
[M]aintain a written informed consent signed by the patient … for all treatment plans and procedures where a reasonable possibility of complications from the treatment planned or a procedure exists, or the treatment plans and procedures involve risks or hazards that could influence a reasonable person in making a decision to give or withhold consent. Such consents must disclose any and all complications, risks and hazards.
22 TAC § 108.7(7). The provision has some wiggle room (e.g., reasonable possibility of complications, reasonable person); but, I have seen Board reviewers and ISC Panelists try over the past few years to expand the times when written consent is required.
I addressed two such areas as part of my informal survey. First, with respect to obtaining x-rays, the respondents were split fairly equally between obtaining written consent with each x-ray and never obtaining it (with a few “first x-rays only” responses). One could argue (and I have argued) that informed consent is not required for x-rays because of the infinitesimal risk of harm (pregnant patients excepted).
Second, I asked about signed written consents for examinations and, again, the responses were equally divided between every visit and never. Again, I have argued in prior ISCs that an examination poses almost no risk of harm and that no reasonable patient would refuse an exam based on some miniscule risk. One conclusion that can be drawn is that many dentists have their patients sign written consents because of the requirement, while many do not do so since there is very little risk of complications from an exam or an x-ray.
All of the “issues” outlined in this article can be considered to be “low-hanging fruit” for dentists. They will never be an issue unless there is a Board complaint or investigation, in which case the absence of this documentation will be an issue, especially if the Board’s reviewer has issues with the actual treatment (as opposed to the records that portray that treatment). It is, therefore, good practice to take and document vital signs yearly, ask patients whether their medical history has changed at any visit where invasive treatment is discussed and before it is undertaken, and ask patients to update their medical history forms at least every year or two.
[1] Although one could argue that record-keeping requirements are different than we know as the standard of care, in the realm of Board investigations and hearings, the Board generally considers record-keeping as part of the standard of care.