The Teenager Who Drove Himself

Every name on your schedule has a date of birth beside it. Your software has already done the subtraction, so the front desk knows which of today's patients are under eighteen. What the schedule does not show is who is coming through the door with them.

Most of the time it is a parent. Sometimes it is nobody. A seventeen-year-old with a license and a car walks up to the counter for a cleaning his mother booked, and he is by himself.

Nothing is wrong in that picture. But two questions walk in with him, and the scheduling coordinator is the person who has to answer both. May he be seen today? And afterward, who gets told what?

The first question belongs to your state

An earlier post on this blog covered who may sign for a child, and the short version holds here: consent for a minor's treatment is a matter of state law, and the ADA's guidance sends you there instead of answering for you.

The ADA's page on consent for minors does carry one sentence about this patient in particular. "Dentists need to be aware of when they can properly defer to an adolescent patient for information instead of requiring the parents to provide it." Read that with the counter in mind. He can certainly tell you his tooth has been bothering him. Whether he can update his own health history, or agree to radiographs, is a different matter, and the page does not say. It says nothing at all about a minor who arrives without a parent. No national rule covers that moment. Every practice is working it out from its own state's law and its own judgment.

So the useful line is one the doctor has to draw: being present is not the same as consenting. A cleaning a parent scheduled, on a consent form the parent signed, is one kind of visit. The visit where the doctor finds something and would like to treat it today is another kind, and the adult who can say yes is not in the building.

The second question has a federal answer

Here the team's instinct usually runs the wrong way. He drove himself, he looks grown, so surely what happens at his visit is his own business.

Under the HIPAA Privacy Rule, in most cases it is still his parent's business too. The rule treats a parent as the minor's personal representative, and it lists the situations in which the minor acts for himself instead. One is where "the minor consents to such health care service" and "no other consent to such health care service is required by law." Another is where he "may lawfully obtain such health care service without the consent of a parent." The last is where a parent "assents to an agreement of confidentiality" between the minor and the provider.

A driver's license is not on that list. And last December the Office for Civil Rights, which enforces the rule, sent a letter to providers on exactly this subject. It says the exceptions "are generally limited to certain types of health care services, such as mental health care," that a provider "may not place additional limitations on a parent's access," and that "OCR is making parental access to children's medical records an enforcement priority." The letter never mentions dentistry. It does not need to, because a dental practice is covered by the same rule.

So picture his mother calling afterward to ask how the visit went and whether he needs anything done. The coordinator who answers "I'm sorry, he would have to give us permission" has added a restriction the federal rule does not contain, unless your state's law puts one there.

What he says when no parent is in the room

Now the other direction. The same ADA page observes that "adolescents may not want to speak about certain medical conditions" with a parent listening. The other side of that is plain enough: a teenager alone in the chair may say more than he would with his mother beside him. The page's advice to the clinician is short, "Avoid lecturing or judging," and it asks the dentist to "reiterate the need for them to advise their parents or guardians of the situation."

Then comes a sentence written for the whole office. "As the leader of the dental team, it is your responsibility to make sure that every employee in the practice, clinical and non-clinical, is familiar with state laws regarding the protection of information that an adolescent patient may share, either knowingly or unintentionally."

Clinical and non-clinical. The coordinator who takes the mother's call is in that sentence. So is whoever scans the health history he filled out on his own.

Put the two sources side by side and they pull against each other, which is honest, because the law does too. The federal default is that the parent may know. The ADA's reminder is that your state may protect some of what he told you. And where the Privacy Rule leaves any room for a decision, it gives that decision to a "licensed health care professional, in the exercise of professional judgment." That is the doctor. It is never the person who happened to answer the phone.

The page the desk needs

None of this can be worked out at the counter with him standing there. It can be written down ahead of him, and the page only has to answer a handful of things.

Whether a minor may be seen without a parent present, for which kinds of visit, and what has to be on file first. What gets asked on the booking call so the answer is known before he arrives, starting with who is bringing him. What happens when a routine visit turns into a conversation about treatment, and who reaches the parent. What the coordinator tells a parent who calls afterward, which in the ordinary case is a plain account of the visit. And the one route around that: if the patient told the clinical team something he asked them to keep private, the coordinator does not weigh it herself. She says the doctor will call back, and the doctor does.

Have your attorney and your malpractice carrier read the page before the team does. The answers differ by state, and some of them will surprise you.

Keeping the answer where the desk can find it

Saige is the team-side assistant in AiroDental, and it holds pages like this one. A scheduling coordinator can ask in her own words, "can a seventeen-year-old come in alone for a cleaning?", and get back what the doctor wrote for this practice in this state. When the doctor changes the page, the next person who asks gets the new answer. Saige works with your team. The conversation with the patient, and with his mother, stays with the people at your desk.

If your desk answers this one from memory today, it is a good page to write next. There is no long-term contract and no onboarding fee. See how Saige holds your policies.

General information, not legal advice. Whether a minor may be seen without a parent, and what a parent may be told, are matters of state law; confirm your policy with your attorney and malpractice carrier.

Deren Flesher, DDS. Founder, AiroDental.