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28 July 2025

Why documenting treatment options matters

Accurate and comprehensive clinical notes are fundamental to high-quality dental care and professional risk management. For dental practitioners, meticulous documentation is not just best practice; it is essential for delivering high-quality care and safeguarding both patients and practitioners. Other than recording the diagnosis and procedures performed, it is important to also document the treatment options discussed with patients-including their risks and benefits, as well as the patient’s consent or refusal. 

1. The legal and ethical imperative

Dental practitioners operate in a climate of increasing patient awareness and regulatory scrutiny.

 As part of the informed consent process, it is essential to document the presentation of treatment options, along with their associated risks and benefits. This may involve, for example, simply documenting the option regarding a referral to another practitioner and including the rationale for the option of referral, or recording all the various treatment options (and their risks, benefits and limitations) considered during a consultation for cosmetic dental treatment. 

This record serves as evidence that the patient was fully informed and participated in decision-making. Failure to document the discussion of treatment options and associated risks/benefits and limitations leaves practitioners vulnerable in the event of a complaint or claim.  If a patient later claims they were not informed of treatment alternatives along with their risks or benefits, and if it is not documented, the patient’s account may be accepted over the practitioner's. 

The revised shared Code of Conduct (the Code) came into effect on 29 June 2022. The Code references health records under: 

Principle 8-Professional Behaviour

8.3 Health Records

“a. Keep accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners.”

AHPRA and the  Dental Board of Australia have self-reflective tools for health records to assist practitioners with their obligations under the shared Code of Conduct both of which refer to the recording of treatment options in the clinical record.

2. Improving communication and trust

Documenting treatment options—including when a patient declines a recommendation—demonstrates respect for patient autonomy and fosters trust. Clear records of these discussions:

  • Help patients recall complex information, especially about long-term risks or alternative treatments, which may be forgotten over time.
  • Provide a reference for future consultations, ensuring that care remains consistent and patient-centred.
  • Encourage patient engagement and adherence, as they feel their preferences and concerns are acknowledged and respected.

3. Defending against complaints and claims

In everyday dental practice, there are inevitably occasions when adverse events occur or clinical outcomes fall short of patient expectations despite appropriate care and planning. When patients experience complications or express dissatisfaction with the outcome-they often express they were not made aware of other available options. Clinical issues related to dental treatment may not present for months or even years, making it understandable that patients may not recall prior discussions regarding treatment options and alternatives.

In such cases, contemporaneous notes documenting the discussion of treatment options and their risks and benefits may be the deciding factor in defending against claims where patients claim that other options were not presented.  Without this documentation, even the most diligent practitioner may struggle to demonstrate that proper consent was obtained and that the patient was fully informed.

4. In regard to treatment options what should be documented?

  • A summary of all treatment options, no matter how unlikely to be accepted, also include offer to refer (if practitioner not able/not willing to provide that treatment) along with the rationale for referral
  • Be specific-list each option individually
  • Discuss and document the rationale, risks, benefits and limitations of all the treatment options
  • Discuss and record the fee for each treatment option, along with how the fee will be paid, any further fees, what will happen to the fees if treatment is not completed.
  • Discuss and record any diagnoses that will not be treated as part of the agreed treatment plan and the associated implications
  • The patient's questions, concerns, and preferences.
  • Discuss and document any additional issues such as, patient compliance requirements, appointment scheduling, medications that need to be considered as part of the treatment options
  • Evidence of informed consent or refusal-this can be verbal or written, and it is important that it is recorded in the clinical record. It is recommended that written consent is obtained for more complex treatment.
  • Updates to the treatment plan as new information emerges or as the patient’s condition evolves.

5. Conclusion: A professional responsibility

Documenting treatment options is not just good practice—it is a professional and legal responsibility. Comprehensive documentation, inclusive of treatment options, supports patient-centred care, ensures transparency and provides protection for practitioners in an increasingly complex health environment. 

For those seeking a refresher on dental records and consent, an online Clinical Records and Consent course is available at a discounted rate for ADAVB members. Registration is via the ADAVB website: Dental Compliance Australia-Dental records and consent course

References:

Dr Maria Guida
BDSc FICD
ADAVB Dental Consultant