Documenting Non-Compliance

Mr. Jones has come in again for the same problem that isn’t healing. You told him to stop smoking, and even though he denies that he’s smoking, he reeks from cigarette smoke. What do you do?

It could be any patient with any type of non-compliance. Even though you’re tired of telling him or her that they need to (fill in the blank – stop smoking, brush more thoroughly, floss, etc.), you need to remind them each time they come in to stop a behavior, or start a behavior, or do a better job. If you don’t, the patient will think he or she “got away with it.” Similarly, you need to briefly document your conversation with the patient (re-stating the instructions and why it is necessary to do what you instruct).

If you don’t re-instruct the patient and a problem occurs because of the behavior, the patient won’t hesitate to blame it on you because you didn’t properly instruct him or her. It’s not fair, and it requires a bit more time to have the conversation and document it. But that time is well spent compared to the time it could take to defend yourself from that patient’s claim for damages.

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