5.2.10 - Patient Reconciliation

In addition to completing minimum clinical experiences for graduation consideration, the student must also reconcile all assigned patients including all those initially assigned for complete treatment, patients accepted as a transfer, and patients provided limited care. Reconciliation involves planning the process for continued care (or removal from the program) prior to graduation and is expected of every student to complete the graduation sign-out process.

There are four methods for patient reconciliation:

1. Completion of Treatment
2. Transfer to Another Student
3. Patient Release
4. Completion of Limited Care

Completion of patient treatment is the most desirable method of patient reconciliation, and it is, therefore, highly recommended that students make patient assignment requests based on their ability to manage the patient’s care until completed. If a student requires counseling regarding their ability to manage their patient family, an appointment should be made with their faculty advisor.

Release involves the removal of a patient from the program and the discontinuation of treatment. This action will only be implemented for legitimate causes including (but not limited to):

• Inability to pay for treatment
• Lack of interest in the program
• Unwillingness to accept treatment recommendations
• Moving out of the area
• Three or more cancellations and/or failed appointments
• Severe behavioral management problems
• Unavailability for regular appointments
• Formal referral to a collection agency
• The patient requested to discontinue treatment
• Treatment not within the scope of the program – too complex

It is not acceptable to release a patient because of race, sex, age, or occupation.

It is also not acceptable to deliberately neglect a patient whose needs do not coincide with your expectations or academic requirements. Patient neglect is a punishable offense and will be discussed in the Patient Abandonment, section 5.2.10.3.

Never confront a patient with release without justifiable cause. To request release, see your Group Practice Director and PSC. A patient should never be confronted with dismissal unless the student has sufficient evidence that a valid reason exists. Always consult with the Director of Patient Relations before you consider these actions and certainly before the patient is informed.

The release of patients from the predoctoral program must be accompanied by proper documentation, which should include any information that may affect the future interactions of both the student and the College of Dentistry with the patient (financial difficulties, scheduling conflicts, unwillingness to accept planned treatment, mutual agreements to defer treatment, lengthy unavailability for treatment, etc.). Questionable patient releases require authorization from the Director of Patient Relations.

A single canceled or missed appointment is not reasonable grounds for release. While patients must be available at least two half-days per week, students will seldom see any patients more than once a week. If a patient is only available outside the normal clinical patient expectations, this may not be grounds for dismissal provided that their schedule coincides with the current available clinic time. The student should be reasonable and flexible with their expectations or the patient should be reassigned to a student who has clinic time available when the patient is available.

It is extremely important that the student establish authority regarding the College of Dentistry policies early in the relationship. Therefore, the student should be very familiar with the information in this manual and should be able to respond to questions regarding school policies. The student should tactfully dictate the frequency of appointments, determine treatment sequencing, and inform the patient when their actions may jeopardize their status in the program (frequent cancellations/no-shows, failure to pay account balance, etc.)

A patient referred to the College’s collection agency is automatically released even if you have not requested this action. You will not have access to any electronic record in collections without the permission of the Central Billing Office.

A patient may request reactivation if the reasons for the original release no longer apply. Reactivation of a patient referred to a collection agency will not be allowed. The Director of Patient Relations must approve all reactivation of released patients.

Infrequently, a patient may be notified through a letter of pending release regarding the nature of one of the above-listed problems that may be the cause for release if the circumstance does not change. Patients are given 2 weeks (10 business days) to appeal the release, if no response is received, the patient is processed for the final release.

Dental students may request an assignment of a Limited Care patient at any time by electronic submission. Limited Care Patient Requests are to be submitted electronically to the Director or Patient Relations. While assignment requests will be filled in the order they are received, there may be times when a request that is too specific will delay the process and other requests will be considered for assignment in the interim.

Additional considerations regarding the assignment:

• Students must have a Limited Treatment request on file for assignment.
• Students will be allowed 2 (two) Limited Treatment patients in their patient family.
• Students will not be assigned another patient until treatment is resolved on the previous patients assigned to them.
• Students must complete all Limited Treatment assignments. Patients will not be re-assigned.

Once the student has accepted a Limited Care patient, they are responsible for every procedure specified on the form including any required follow-up care.  Limited Care patients may be taken directly to the proper clinic(s) for treatment or consultation as necessary; a work-up and treatment planning is not needed unless requested by consulting faculty. The Workflow for Limited Treatment Patients can be found in the Clinic Binder in each clinic faculty office. The “official” Clinic Binder is now available in axiUm. The location is axiUm/Links/Clinic Binder.

Abandonment - a unilateral termination of the patient-physician relationship by the physician without notice to the patient.

The relationship between physician and patient generally continues until it is terminated by mutual consent of both parties.  However, a relationship can be discontinued through the dismissal of the physician by the patient, the physician's withdrawal from the case, or the physician’s services are no longer required.  Failure to follow up on patient care after the acute stage of illness has subsided or neglect to give patient warnings of necessary instructions may involve the physician in serious legal difficulties.  Premature termination of treatment is quite often the subject of legal action.

Closely related to this type of problem is one which occurs when the physician, though not intending to end the relationship with the patient, fails to ensure the patient’s understanding that further treatment of the complaint is necessary.

The following elements must be present for a patient to recover damages for abandonment:

1. Unreasonable discontinuance of medical care.
2. Discontinuance of medical care against the patient’s will: termination of the physician-patient relationship must have been brought about by a unilateral act of the physician. There can be no abandonment if the relationship is terminated by mutual consent or dismissal of the physician by the patient.
3. A physician’s failure to arrange for care by another physician or refusal by a physician to enter a physician-patient relationship by refusing to respond to a call or render treatment is not considered abandonment. A plaintiff will not recover damages unless it can be established that a physician-patient relationship has been established. (i.e., Buttersworth v. Swint, 186 E.E. 770 (Ga. 1936)
4. Foresight that discontinuance may result in physical harm to the patient.
5. Actual harm suffered by the patient.

The relationship between a physician and patient, once established, continues until it is ended by mutual consent of the parties, revoked by the patient’s dismissal of the physician, by the physician’s withdrawal from the case, or until the physician’s services are no longer needed. A physician who decides to withdraw his services must provide the patient with reasonable notice so that the services of another physician can be obtained.

The Director for Quality Assurance and Director for Patient Relations will not tolerate willful abandonment, and has joined the Department of Pediatric Dentistry in establishing the following guidelines to aid in determining if abandonment has occurred:

1. Willful or undocumented failure to see patients with treatment needs within the semester assigned.
2. Failure to see any patient for two consecutive semesters without sufficient documentation in the record to justify such failure to see the patient.

In cases where abandonment has occurred, a grade of “F” will be given for the Clinical Record-Keeping and Patient Management course for the semester during which the incident occurred.