An assistant looks apprehensive about an angry patient.

When Your Patients Have Poor Behavior

With the goal of providing a safe environment for staff and patients, it is essential to have a policy in place around bad behavior, such as what is grounds for patient dismissal.

Earlier this year, the Dental Defense Union of the UK released information that dentists were reporting an increase in patient violence. With the goal of providing a safe environment for staff and patients, it is essential to have a policy in place around such bad behavior, such as what is grounds for patient dismissal.

This could include verbal abuse, threats, assaults, drug-seeking behavior, failure to comply with recommended dental treatment, sexual harassment and more. The procedures part of this policy should explain how staff and patients will be protected when unacceptable behavior presents itself.

When to Dismiss a Patient Immediately

Most dentists are familiar with the general rule of providing 30 days of emergency care and referral to a source, such as the medical society, in the patient notification. However, if the patient is threatening violent or criminal activity, immediate termination is acceptable. If the behavior is directed toward staff, it is important that the healthcare provider or practice manager intervene while it is happening.

Your documentation should clearly and objectively document the patient’s behavior. If the patient is using profanity, it is not necessary to put the words verbatim in the records. You can use a combination of letters and symbols so anyone reading the chart will understand the words used.

Additionally, review your documentation to make sure it provides objective data to support your dismissal decision. 

Step by Step: Dismissal Policies and Procedures

  • Discuss with the patient your decision to dismiss (if appropriate)
    • Document the discussion in their records, including any witnesses who might be present (family members, staff)
  • Send a letter regarding the dismissal to the patient both by certified mail (with a return receipt) and regular mail marked “personal and confidential”
    • If the certified mail is not claimed and/or the regular mail is returned unclaimed or undeliverable, mail it again
      • If it is received back a second time, maintain it  (with the envelopes with the markings) in the records as evidence of your attempts
    • If your letter includes who witnessed the discussion/altercation in your office
      • Reference their presence at the discussion/altercation in the letter (such as your wife, your son, etc.)
      • Do not include the surnames of your staff; be generic by using their title instead (e.g., my nurse)
    • You can reiterate the reason for the dismissal, keeping the statement professional and objective:
      • Describe any urgent conditions of which the patient should be aware, being sure to finish any procedures that you have started before the dismissal
      • Include the necessity of continuing care
    • Include a copy of the letter in the patient’s records, along with the certified mail receipt
    • State that medication and refills will not extend beyond the 30-day transition period or the immediate termination date
    • Clearly include the date that care with your office is terminated
    • Recommend the patient visit the local dental society or a dental referral service to seek further treatment
    • Offer to transfer the patient's records to another provider with the appropriate release (include the release in your letter)
    • Decide if you want to agree to see the patient only on an emergency basis during the 30-day transition period
  • Document the patient’s medical condition and stability prior to the termination
  • Inform the staff of the dismissal from the practice
    • Make sure they know how to address the situation if the patient contacts the office
      • No future appointments should be scheduled
      • No medications refilled
  • Confirm the dismissal is in compliance with any third-party payer guidelines
  • In a multi-provider group, consider dismissing the patient from the entire group—not just the current healthcare professional
  • Be aware of possible Americans with Disabilities Act (ADA) accusations that might arise, and discuss any concerns with your practice attorney
  • Be aware that the patient may express their frustration on social media

Because state regulations may vary, always be sure to check with your attorney when establishing policies. It is critical that you adhere to local and national mandates.

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