There are essentially three categories of communications that are used in an orthodontic office: intraoffice, interoffice, and extraoffice. Intraoffice pertains to all internal forms and communication tools that one uses to enhance procedures and office efficiency. Extraoffice entails all communications between the office and patients, third-party payors, administrative agencies, etc. Interoffice communications deals with all correspondence with other offices having to do with the interdisciplinary treatment of your patients. Occasionally, some of the communications will overlap categories due to the complexities of private practice today. This article will discuss the risk-management principles behind various interoffice communications.

The First Letter

The first interoffice communication generated is after the patient has called your practice and has had an initial screening. It begins with thanking the dentist for referring the patient. If a GP was not the referral source, it allows you to notify him or her that you have seen the patient and either

1. treatment is presently recommended;
2. the patient's problem is best treated via recall observation; or
3. the patient has decided not to take advantage, for whatever reason, of the benefits of treatment.

This is important because often the orthodontist will be able to defend against a claim of misdiagnosis, failure to recommend treatment when it was indicated, or neglecting to treat if treatment was indicated if, in reality, it was the patient who refused to accept therapy. It will also indicate whether the patient is foregoing recommended therapy at this point in time (see Form A). Both of these scenarios commonly occur in root resorption cases secondary to ectopically erupting canines.

Form A provides the appropriate communication for all options relating to the patient's initial screening visit.

You may also encounter a patient who does not have a general dentist, and you now have the opportunity to refer them to one. In this case, you should send your standard introduction letter to three local referrers, allowing the patient to choose between them. By reciprocating to three different referrers for all of the referrals they have previously given you, you are killing three birds with one stone.

Once you have determined a treatment plan, most offices send out synopsis letters. Virtually every practice-management software package has one. Many offices send out two: one to the patient and one to the GP. The synopsis letter is both a great practice-management and a great risk-management tool. The problem comes when these letters are used incorrectly. The most common error is when the synopsis letter to the patient paints a "sunny, blue skies" kind of picture, while the letter to the dentist depicts a "storm clouds on the horizon" image. When the case goes south and the parties are in court, it is difficult to reconcile the discrepancies between the letters. Usually the result is that the patient claims that vital information was withheld from him or her, resulting in a claim for lack of informed consent—an easily reached conclusion based on the orthodontist's reluctance to note in the patient's letter any of the potential negative sequelae or problems that were prominently mentioned in the letter to the GP.

Medical History Letters

When treatment is about to begin, there are a number of form letters that the orthodontist needs to keep in his communications arsenal. Besides being great risk-management tools, they have a strong practice-management component as well. The first one is a general letter to the patient's physician inquiring into whether or not the patient has any medical conditions that might impact receiving orthodontic therapy (see Form B).

While all of this information was available from the patient's medical history, it is a belt and suspenders type of risk-management position one should adopt. In addition to its low cost and high return ratio, it carries the potential to become another referral source as well.

The next letter is a specific one relating to patients who present with a positive history of cardiopathy that may require antibiotic prophylaxis. It asks the cardiologist about the nature of the disease, whether or not SBE prophylaxis is recommended, and, if so, what regimen to follow (See Form C). If you send out this letter or make a phone call to elicit the same information, make sure you get a response. There is nothing worse than knowing you need to make a referral, making it, and than ignoring the response or not following up on not having received one.

The next letter is for the ENT physician, allergist, and/or pediatrician. It alerts the medical specialist to your clinical and radiographic findings and inquires into whether or not there is a history of, or treatment for, nasorespiratory embarrassment, eg, tonsils, adenoids, turbinates, or sleep apnea; and if there is, to treat appropriately and keep you in the information loop (see Form D).

Forms B through D should be used as often as possible for the patient's protection, your protection, and to keep your name in the forefront of the local medical community.

Clinical Letters

Once you know who the patient's other treating dental health care providers are, you must have a stable of letters for various clinical situations that unfold. The requisite communiqués include, at a minimum, a periodontal evaluation letter (E), a caries exam memo (F), and a surgical procedure prescription form (G).

FORM G

Dear Dr

In conjunction with (Name)'s orthodontic therapy, please:
[ ] extract
[ ] expose
[ ] consult on
[ ] provide the following:

Remarks:

From a risk-management perspective, the only real requirement is to maintain a copy of every communiqué in some fashion in the patient's record.

Poor Cooperation Letters

There are times when all is not going as planned. For these instances, you must have two poor cooperation letters. The first is to notify the patient or parent that without the necessary level of cooperation on their part, treatment results may be compromised. In the event that lack of cooperation gets so bad, you will want to notify the patient that unless the tenor of the relationship changes, they may be subject to early dismissal. At some point, you will have to notify the general dentist that patient cooperation is lacking and request that they intercede if at all possible (See Form H). They too need to know that treatment may be compromised and that there is the possibility that treatment may be discontinued early because of the poor risk/benefit ratio of continuing to treat a noncooperative patient.

These types of letters have saved many an orthodontist from malpractice suits or have helped to minimize jury awards. The caveat is that after a certain number of these have been sent, you must act affirmatively regarding patient dismissal. To do otherwise is to engage in what is known as supervised neglect.

Completion Letters

You also need to have four completion letters, two for Phase I treatment and two for comprehensive treatment; in each case, one goes to the patient/parent and one goes to the GP. Again they need to say essentially the same thing. The Phase I letter (see Form I) alerts both the GP and the patient that a) the first phase of treatment has been completed, the treatment goals were or were not met, and the patient will be kept under observation for the need for Phase II. Everyone needs to be on the same page that phase one was only that and was not comprehensive therapy.

The second set of letters is again for both parties and again outlines what was and was not accomplished, what type of retention is required, and whether or not long-term observation is necessary and for how long (see Form J). It should also indicate who is responsible for monitoring any fixed retention employed.

While there are certainly other interoffice communications that occur on a daily basis, the ones previously referred to have important risk-management components. Properly structured and worded letters can mollify the daily stresses associated with practicing in an increasingly litigious atmosphere. Having your practice-management advisor or legal counsel review your communication forms is an important component of prudent practice.

Laurance Jerrold, DDS, JD, is the dean and program director of postgraduate orthodontics at Jacksonville University School of Orthodontics and is a nationally recognized dental risk-management educator. He can be reached at .