Recording Problematic Behaviors of Dental Patients

Many CPG clinics insured by NORCAL Mutual provide dental services. Occasionally, clinic providers must cope with problematic behaviors exhibited by dental patients. Several dental clinics have reported patient behaviors so extreme or disruptive that the providers have desired to terminate the patient relationship. Unless there is documented evidence of the behaviors, however, it can be difficult to defend a decision to discharge the patient and terminate the relationship.

The volume of calls to Risk Management related to problematic patient behaviors in dental clinics has increased roughly four-fold in the past year. Dental providers in clinics are learning what many medical providers have long known—documentation is an important factor when making a decision to terminate a patient relationship. Once a relationship is terminated, a patient may claim abandonment or otherwise unfair treatment by the provider. But as is the case with medical records, a thorough dental record can be an important defense tool. It can reveal a pattern of problematic behavior that substantiates the need to terminate the relationship.

Any staff member who encounters a patient and provides care, supportive education or service should document the interaction and/or care provided. This includes appropriately describing problematic behaviors on the part of the patient. If a patient has exhibited aggressive behavior or made threatening or abusive statements in the clinic, this should be documented in detail.

Identify the problem
Problematic behaviors reported by dental providers include repeated "no shows" and late arrivals for appointments. Other providers have reported receiving multiple complaints from patients critical of the dental work they receive—complaints sometimes delivered with abusive language, threatening posture, and even physical abuse.

Some providers have expressed concern that patients have not followed up on recommended self-care measures and, as a result, must be seen repeatedly for the same problems. Others have concerns about patients who threaten to sue the provider or make a report to the Dental Board for health problems that relate to their own non-adherence to treatment recommendations or follow up.

Most clinics have zero tolerance for physically abusive behavior. If documented, such behavior may be justification for immediate termination of the relationship. Most other problematic behaviors, once documented, can also lead to a decision to terminate. As with any decision to terminate a patient relationship, consideration must be given to the patient’s current state of dental health, the treatment in progress, and accessibility of other dental providers in the area.

As well as having policies and procedures in place to assist staff in consistently handling disruptive patient behaviors, clinics need to train staff to document problematic behavior appropriately. The patient record is the "witness whose memory never fades" and can often provide a defense for dental clinic providers and their staff from claims of unfair treatment or of abandonment.

The key to good documentation is to be objective and descriptive but not derogatory. Personal opinions are not appropriate. Also, consider these risk-management recommendations:

  • Ensure that all providers and staff who interact with patients document the care and service provided.
  • Be sure all entries are legible as well as dated, timed and signed.
  • Document problematic behaviors objectively, including non-adherence or potentially harmful patient actions.
  • Document pertinent discussions with the patient, family, and other healthcare providers, including those that occur by telephone, letter, fax, email, etc., both during and after office hours.
  • Note if the patient left without being seen and what follow-up actions were taken.
  • In the event of a threatening or violent encounter, document if police were called and what actions were taken.
  • Avoid documenting value judgments, accusations, and derogatory or other non-objective remarks about the patient and others who were present at the time of the incident.
  • Do not make reference in the patient's record to incident reports, unusual occurrence reports or other types of internal risk management reports, or to conversations and advice received from your malpractice insurance company or attorney.

Try to change the behavior
Whenever possible, it is preferable to work with patients to try to change problematic behaviors before terminating the relationship. For example, try to schedule a chronically late patient at the end of the day so the schedule doesn't get backed up. Place reminder calls the day prior to an appointment. When a patient uses foul language, remind him or her of patient's rights and responsibilities for receiving care in your clinic (and provide a copy of same).

Sometimes noncompliance is really an indicator that the patient simply doesn’t understand the treatment plan or recommendation. The likelihood of patients adhering to follow-up instructions is dependent on their understanding of the reason for the care, the expected outcome, and the risk of not complying with or adhering to follow-up advice. Patients need to know they play an active role in their dental health decision-making process and that their input is respected and valued.

Educate the non-adherent patient regarding the benefits of the proposed treatment and the risks of failing to follow recommendations. If the patient continues to refuse to comply, consider asking the patient to sign a "Refusal of Treatment" form. Remember to document this "informed refusal" and the attendant conversation describing the educational information and benefits of compliance, as well the risks of not following recommended treatment.

Making the decision to terminate the relationship with a non-adherent or disruptive patient may not come easily, but doing so will be easier if the patient's record reflects the sequence of events that led up to the decision. Such documentation takes a concerted effort by everyone involved in the patient’s dental care, treatment and follow-up.

Every patient situation and issue is different and may bring documentation challenges. Remember, questions and situations can be discussed with a Risk Management Specialist from our NORCAL Risk Management Department.

NORCAL Risk Management Resource Documents:
(available at in the Claims Rx & MyCME section under the Risk Solutions tab of MyNORCAL)

  • Documentation
  • Charting Dos and Don’ts: Making a Difference in the Defense of Care
  • Physician-Patient Relationship: Termination of the Relationship

Additional Resources: California Medical Association On-Call Documents:
(available at

  • Document #1135: Contents of the Medical Record
  • Document #0805: Terminating the Physician-Patient Relationship

Chapman Insurance Founder Looks Back, Moves Forward

terry chapmanYou could call Terry Chapman the godfather of insurance for nonprofits. He launched his brokerage, Chapman Insurance, in 1973, when few brokers took notice of the insurance needs of community healthcare clinics and other social service agencies. His goal was to meet the needs of the nonprofit community — a goal from which he has never wavered.

The company — the exclusive broker for the Clinic Purchasing Group (CPG), NORCAL Mutual's program for clinics — has grown steadily over the years and today has about 2,100 clients.

How it started
In the early 1970s, Terry and his colleague Mary Lai traveled around California for United Way, helping out social service agencies with their insurance needs. "We became experts in the subject," he recalls. (They eventually co-authored, with Elmer Steinbock, the book Am I Covered For…? A Comprehensive Guide to Insuring Your Non-Profit Organization, widely known as the “bible” on the subject.)

Meanwhile, free health clinics were springing up to take care of uninsured young people, many of whom needed treatment for sexually transmitted diseases and drug-related health issues. The first was the Haight-Ashbury Free Clinic in San Francisco, followed by others in Pasadena, Los Angeles, Laguna Beach and San Diego.

The clinics relied on volunteer physicians and hospital residents, none of whom had insurance for clinic work. So the new brokerage addressed the need.

"We designed a policy that would work for them, as a service to the community," Terry says. "Insurance became even more important to these growing clinics when they sought federal funding and found out that without insurance, the government wouldn’t help them. We wrote all the free clinics."

The Creation of CMIC
"When we started out, there were about seven carriers covering our healthcare clinics," he recalls. "But the carriers would come and go, not because of their clinic business but because of other lines that caused them problems, such as trucking or financial guarantee bonds. The clinics kept having to change carriers."

The clinics finally realized that the key to their insurance stability was to have their own company. In 1986 they created the Clinic Mutual Insurance Company (CMIC), with capital support from Lloyds of London. (Terry even mortgaged his house to raise a capital shortfall, hoping that CMIC would be able to pay him back. They did so within two years.)

CMIC ran well for ten years. In the late 1990s, the Federal Tort Claims Act (FTCA), the statute by which the United States authorizes tort suits to be brought against itself, was expanded to include community health care clinics. Overnight, the personnel of covered clinics "became almost like federal employees," Terry says.

"They were now covered for malpractice most of the time. As a result, CMIC saw a decrease in premium and also in exposure. CMIC realized it would be prudent to partner with a larger carrier. The board of directors interviewed three carriers and chose NORCAL Mutual."

In 1997, NORCAL Mutual assumed the book of business of CMIC, with roughly 120 clinics in California and other Western states. Now known as the Clinic Purchasing Group (CPG), the program has grown to more than 230 clinics.

In addition to serving non-FTCA clinics, CPG serves FTCA clinics by offering primary insurance for claims that the government refuses to defend. For example, if a clinic is giving physical exams to school children but doesn’t have permission from the federal government, then there’s no coverage for that service.

How important is this insurance? Terry cites clinics that have dropped their additional coverage with NORCAL, only to come back after a few years, sadder but wiser. They know now there are loopholes in the system.

Room for more growth
"The nonprofit market is huge," Terry says. "We have maybe 20 percent of the market in California. New exposures are arising constantly. For example, charter schools have emerged as a new market; they're becoming a major part of our business."

Although the nonprofit market continues to grow, smaller nonprofits are falling by the wayside. "It's just too tough to survive if you’re undercapitalized," Terry says.

While Chapman's growth has been steady, it took off in a big way under the leadership of Terry's son Greg, who became president of the company in 1999.

"We had five employees when Greg took over, with premium volume of about $15 million. Today we have over 50 employees and about $100 million in premium."

"We have changed our business model to be more consultative. Currently, I'm doing evaluations for the 150 largest accounts."

Terry says that healthcare clinics remain an integral part of Chapman's business.

"The challenges the clinics face are complex and difficult," he says. From a risk management perspective, the insurance needs of the clinics have grown dramatically in recent years because of the ever-wider range of services offered.

"The clinics provide a vital social and public health service. I'm proud that Chapman Insurance can be of service to such an important part of the healthcare system."

Coming in December: Two New Risk Management Webcasts

While purchasing and implementing an electronic health record (EHR) system can have a major impact on a community clinic, there are many things the clinic can do to make the impact positive. In December, the NORCAL Mutual Risk Management Department will release a new webcast that spells out these strategies.

We will also release a new webcast on ways to improve patient hand-offs. Analysis of our claims data reveals that miscommunication during hand-offs often leads to medical liability claims that likely were avoidable.

The webcasts combine video of the speaker and PowerPoint slides to enhance the learning experience. Participants can pause a webcast at any point. Each will be about 45 minutes long and will include continuing medical education (CME) credit opportunities.

The new webcasts, along with "Disclosing Unanticipated Outcomes" (launched last July), will be located in Claims Rx & MyCME under the Risk Solutions tab of MyNORCAL, the policyholder-only section of our website at

How to Successfully Launch Your EHR System
The new webcast on EHR systems, "How to Successfully Launch Your EHR System," will focus on three main areas:

  • The current practice. How well does it handle information? Where can it improve? This is important because an EHR system can make good information management even better, but it can also make poor information management even worse.
  • The people who use the system. How can a practice use policies and procedures to ensure that its people use the system correctly? How can it use training to build a practice team that fully embraces the EHR system?
  • The EHR system itself. How can a practice configure the system to fit into the practice? How can a practice set it up so that it is user-friendly, protects patients and reduces risk?

Hand-offs Along the Continuum of Care
The new webcast on hand-offs, "Hand-offs Along the Continuum of Care," will use many cases from our claims database to illustrate ways communication can break down during hand-offs and how to avoid these problems.

CEO Retires and Successor Named

After eight years as President and CEO of the NORCAL Group, which includes NORCAL Mutual and its wholly owned subsidiaries, PMSLIC Insurance Company, Mechanicsburg, PA, and Medicus Insurance Company, Austin, TX, James Sunseri has retired. During his tenure at the helm, NORCAL Mutual not only remained financially strong but achieved major milestones such as the integration of PMSLIC into the NORCAL Group and the acquisition of Medicus, giving the NORCAL Group a national presence.

In accordance with a planned succession strategy, Scott Diener, CPCU, has succeeded Sunseri. Diener was previously Executive Vice President and Chief Operating Officer for the NORCAL Group. Sunseri will continue with the NORCAL Group as a consultant until January 15, 2012.

Sunseri became President and CEO in 2003, after serving as COO and head of the Claims Department. Even as he orchestrated the operational integration of NORCAL Mutual and PMSLIC, Sunseri began laying the foundation for expansion to meet the needs of physicians in a changing healthcare landscape. Under his leadership, NORCAL Mutual, with its new joint venture partner, launched OB Protect, a specialty program for obstetricians, earlier this year. Also this year, the Company took over management of an RRG specializing in medical liability insurance for general and bariatric surgeons.

"All those who worked with Jim Sunseri over the past sixteen years wish to acknowledge his contributions to our company’s success and extend our best wishes to him," said Board Chair Jaan E. Sidorov, MD. "He has led our organization during a period of increasing challenges posed by a changing healthcare environment and corresponding shifts in the market for medical professional liability insurance. With Jim at the helm, the NORCAL Group positioned itself to continue its role as an industry leader."

Scott Diener's appointment to the position of President and CEO is the culmination of a succession plan that will ensure a smooth transition, enabling the NORCAL Group to continue its consistent record of growth, solid financial performance and exceptional policyholder service. Diener has held executive positions with medical professional liability insurance carriers over the past two decades. He joined the NORCAL Group in 2001 as President and Chief Operating Officer of PMSLIC. In January 2009, he was named Executive Vice President and Chief Operating Officer for the NORCAL Group, reporting to Sunseri.

"I join our board members, employees and policyholders in congratulating Scott as he assumes the responsibilities of his new position," said Sidorov.

NORCAL Mutual Names New VP of Risk Management

NORCAL Mutual, the insurance carrier for CPG, has chosen Dustin Shaver as its next Vice President of Risk Management and Continuing Medical Education. Shaver assumed the role on September 1, replacing Stephen M. Farber, who will retire at the end of October. Farber will consult with Shaver during the transition period.

Shaver has served as Director of Risk Management Services for the NORCAL Group since August 2010. In this role, he was directly responsible for the management of department workflow and ensuring appropriate risk management servicing of key accounts. In his new role as Vice President, Shaver will oversee an integrated Risk Management Department that serves NORCAL Mutual, PMSLIC and other companies in the NORCAL Group.

Joining NORCAL Mutual as a Claims Investigator in 1994, Shaver was later promoted to the position of Claims Manager before moving over to the Risk Management Department in 2008 to be the manager of that department. His many years of work in the medical malpractice claims environment have contributed to his keen insight into the liability risk issues and consequences that often affect insured healthcare professionals.

Shaver has a bachelor of arts degree in Physiology and Cell Biology from the University of California, Santa Barbara.

CME Credit Period Extended for Claims Rx

The period during which an issue of Claims Rx provides continuing medical education (CME) credit has been extended from one to two years, starting with the November/December issue this year. Physicians will enjoy two years of online access to earn CME credit for reading the monthly risk management publication.

The change has been made to accommodate policyholders who miss an issue during the subsequent year and later wish to go back and read it for CME credit.

Also effective January 2012, policyholders will need to complete an online, post-activity quiz and attestation to receive CME credit for Claims Rx. Currently, they can attest online or by mail, but in 2012 Claims Rx attestation will occur online.

This change is necessitated by an American Medical Association requirement that CME activities include an assessment of the learner's performance. The AMA has determined that credit may be awarded only to those who meet a minimum performance level. To support this requirement, we are revising the Claims Rx & MyCME section of the NORCAL Mutual website,, to include brief, post-activity quizzes.

When in doubt as to which issues they have read for CME credit, users can see a transcript of their completed CME activities in MyCME.

To access CME activities, policyholders log in to their MyNORCAL account, select Risk Solutions, then Claims Rx & MyCME. For help in setting up an account, they should call Customer Service at 877-443-7232 to get a Client ID (not the policy number), which is needed to create the account.

EHR System Guide Now Available

Beginning in Summer 2010, NORCAL Mutual has created a proprietary series of articles on how to purchase and implement an electronic medical record (EHR) system. Until now, these articles have been available only online. Now we have combined the articles into Your Electronic Health Record System: How to Purchase, Implement and Optimize, a 78-page guide available both in print and online.

The guide includes the following chapters:

  • Things to Consider Before Purchasing an EHR System
  • Things to Consider When Negotiating with an EHR Vendor
  • EHR Implementation
  • Optimizing Your EHR System

To request a copy of the guide, call Risk Management at 800-652-1051, ext. 2244. The online version is stored in the EHR Tools section of Risk Solutions in MyNORCAL, the policyholder-only section of our website at


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