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Board May Discipline Dentist Over Record Keeping Despite Compliance with Board's Record-keeping Rule

The North Carolina State Board of Dental Examiners found Cynthia Walker, DDS, failed to document in treatment records the reasons for her prescribing narcotic pain medication to a number of patients. The Board concluded this failure violated the Board’s Record Content Rule and violated the standard of care. Dr. Walker petitioned for judicial review.

The Board’s Record Content Rule, 21 NCAC 16T.0101, provides, in relevant part, that the dentist must include the “Name and strength of any medications prescribed, dispensed or administered along with the quantity and date provided[.]” Dr. Walker’s records included this information. However, the Board’s experts testified that omitting the reasons for such prescriptions violated the standard of care, and Dr. Walker acknowledged in her own testimony that the training she received for past record-keeping violations included that dentists were expected to record the reasons for such prescriptions.

The North Carolina Court of Appeals held that Dr. Walker had not violated the Board’s rule but that she had been negligent in the practice of dentistry by not meeting the standard of care. It rejected Dr. Walker’s argument that the Board could not discipline her for negligence in her record keeping because the Board had a rule on the subject, and she had not violated that rule.

Walker v. The N.C. State Board of Dental Examiners, COA15-337 (N.C. Ct. App. Feb. 16, 2016)

Susanne Newman