Clinical Notes Diary Review

Please follow and like us:

I have reviewed my own “Patient Information and History” record and what is curious to me is under “Medical History”…

I never checked the little box beside ‘Allergies Seasonal” because it did not apply to me. I ONLY checked the things that DID apply to my history…

BUT…..while looking over the “Clinical Notes” on 4/20/2009…….the very first statement (claiming I said yes) is not true.

The statement on the clinical notes states “Pt states periodic nasal sinus problem” when in fact I stated the opposite, that I didn’t have this problem …..only an occasional sinus cold like the normal human has.

I think the assistant writing this could have been Lindsey, the assistant that “suddenly left” the same day Dr. Bourne left,…but it could have been the assistant, Holly…who is still working at Canyon Vista Dental Care…..and for the life of me I don’t know why this first statement was either put in wrong (opposite of what I stated) or changed. I feel, at this moment, like Dr Trevor when he stated “We’re Perplexed” on numerous occasions about my pain and condition that I find myself in because I have no idea why this is supposed to be my statement when I never said that. I do remember Dr Trevor asking me the same question ” have you ever had a history of sinus problems” as to which I replied the same statement as I stated earlier…..no.

In my very first visit I was told by the girls at the front desk that the dental firm was slow, due to the economy and with every appointment I had, the office was either empty, or no more than 1 patient. The time I thought it was more turned out to be the single patient’s family.

The clinical notes are missing the entire recording of my pain. Not one problem I expressed that wasn’t based in their firm is recorded as having happened. There is nothing in the record indicating that I told them the temporary flipper teeth were too long for my mouth. There is no indication in the records of how long topical numbing was allowed to be applied.

6/8/2009 Clinical Notes stated that this was the day I had the extractions…..

I had to ask for antibiotics, not pain medication, and when I did Dr Bourne said if I wanted them then he would give me a prescription but that I “looked healthy” to him! ((((((((((((((((HUH))))))))))))))))))) Nothing in the notes that Bourne drilled on two of the teeth during the extraction process. The entire process of the 7 extractions plus putting the flipper in my mouth lasted about 30 minutes. The back of my tee shirt was soaking from sweat and I was shaking so hard that I had to ask for a lot of tissues to crumple up and squeeze with both hands to try and calm my shakes. Nothing in the notes relates Bourne’s careless jamming of needles in a speed far too fast to control the depth of the injection, and far too forceful to not cause the needle to rip and tear.

Having almost the entire lot of my upper teeth removed was a serious decision for me to make and the only reason for the drastic decision….was to have a “nice smile” which was the whole reason for the decision for a partial in the first place. The temporary flipper teeth were sent back for looking exactly like old man teeth, too tall and ridged and I didn’t see them again until they were placed in my mouth after the extractions. They did not fit. They were pushed to one side of my mouth. They had to be done right.

6/10/2009 Records left out the reason this appointment was postponed.

When the ‘flipper’ was placed in my mouth after the extractions, it was a full plate partial…NOT the half moon partial that Dr. Bourne stated he could do for me because of my severe gagging reflex but he wanted me to try it anyway stating he could trim it if I couldn’t take it this way.

Well….I threw up all that night from the gagging (to me, it was a horrible experience) finally the next day, I followed Bourne’s instruction because he told me to wait 24 hours before I removed the partial to rinse my mouth. When I tried to remove the partial, the clasps on the three remaining teeth were SO tight I was in tears and shedding tears over pain is something I rarely do. After about 15 minutes, I finally got them out and rinsed the vomit from them from the night before. My husband called the dental office and he was informed to tell me to leave them out until the next visit, which I did.

The throbbing began and this was mentioned to Bourne in the next visit but there is nothing in the records of throbbing except “Pt had to take the flipper out because it hurt” Bourne trimmed the partial so I could at least stop gagging when wearing them.

It wasn’t the flipper causing the throbbing in the upper gum because the throbbing continued, sometimes extremely hard. It wasn’t the extractions as even though bones were left in and not one tooth they worked on that stayed is better for it. It wasn’t the inferior chemical used to make the flipper’s teeth, even though it broke me out making even an uneven smile, a smile. It was pain from injuries sustained through a brutal pre-operative Novocain injection speedway. It didn’t matter whether the partial was ‘in’ or ‘out’….the throbbing pain was still there and it was continuous, and growing and increasing.

 ((NOTE CREATED 6/22/2009 @ 12:42:36 pm))

Every single record reference to topical application does not indicate that they never remained able to numb my gums longer than 20 seconds at the most! Bourne was always rushed to get me done. Yet on 6/22/2009 I waited about 20 minutes for Bourne to show up. I sat in that dentist chair, talking to Lindsey who apologized for Bourne’s not arriving, saying he likes to ‘talk a lot’.

This was the last visit I had with Dr Bourne. I told him of the hard throbbing in the gum area (and also the blisters on my upper lip and red line on my lower lip when I wear the partial …(that topic was just ignored by Bourne) but he told me that ‘when a person gets older, it takes longer for things to heal’. I pointed out that the first tooth removal ( the lower right tooth) was almost healed already and I couldn’t understand what would be so different in the top not healing as well as the way the bottom extraction did. It just didn’t make any sense to me but I tried to take his word and considered the throbbing to be just the slow, ””older persons, healing process!””

He removed (filed harshly) a bone from ‘under the gums’ (as he stated to me) (right upper gum) and in the process, pinched and made a noticeable bruise on my upper right lip that even my husband noticed right away when he saw me and asked ‘what happened’ Bourne never removed the bone fragment from the left lower jaw where I showed him, but removed a piece of tooth left where the healing of the extraction was trying to occur….and held it up to the light and showed me. Lindsey was assisting him that day because we had talked about some movies and she wanted me to watch, “Grand Torino” with Clint Eastwood, and asked me to “give her my opinion of the movie” when I had a chance to watch it. Dr Bourne injected the movie “Taken” in order to take part in the dental chair conversation. Both people felt so unknowingly comfortable in their jobs that they referred to the next visit for a personal update on movie preference.

When I left the office, I ran my tongue over the spot on the left side of my jaw and noticed the sharp bone still there. I asked my husband to please call the dental office as soon as he caught up on his work (he works at home) and when he did call, he was informed that Dr. Bourne was NO LONGER with the company and that Dr. Wynn Caffall’s son, Trevor, would be my doctor and an appointment to have the bone fragment removed was made for 6/29/2009 Once again, I didn’t have a choice in doctors.

I had JUST seen Dr Bourne a couple of hours prior to my husbands call…. so naturally I was shocked but was hoping I would get a doctor that would take care of my problems for a change.

(sometime after Bourne’s quick departure, Brenda (the office manager) was asked by me, ‘what happened’….her reply was that Bourne got a job closer to his home in Gilbert.

I asked her….. “where’s Lindsey?”…..her reply was “Lindsey left with him”! Then I asked “and Holly”??? the reply was “Holly is still here.

Bourne had been with the dental firm for two years. His name was on the letterheads, the cards, the office door. I had just been there a couple of hours earlier.

Dr Trevor once stated something about Bourne’s departure that he ‘didn’t know where he was’.

Holly stated to me, when I first saw her after Bourne & Lindsey’s leaving, with my husband in the room, that “they can’t get rid of me” which I responded that I was glad she was there and that I was sorry because I didn’t mean to say anything bad about anyone but I had “tried to trust Dr Bourne but I couldn’t” ….not after he quite loudly proclaimed “SURPRISE” and harshly jabbed a needle in my lower gum…(that was for the first extraction he made) and that ‘that’ was the very reason I decided NOT to have any gas during the upper extractions because I wanted to be aware of everything going on. She stated to me “I don’t blame you…every time he touched you…. he did something.”

Holly was referring to the stitching needle in the top lip on one occasion and another jab from the stitching needle in my bottom lip and also the bruised lip from the last visit with Bourne.

After this conversation with Holly, on each additional visit, she would always tell me after saying something like ‘how are you today’…If I tried to answer with a ‘problem I was having’, she would quickly state…”don’t tell me anything…..I don’t want you to have to repeat everything.” I thought that was a drastic change from the friendly way we spoke anytime before!

My first visit with Dr Trevor was 6/29/2009 where he removed the bone that Dr Bourne missed.

Personally, I liked Dr Trevor……..his abilities were yet to be proven to me. My husband began going alone with me for any visits because he knew what I had already been through with the previous dentist.

Brenda assisted Dr Trevor on that first visit ……..this is when I had asked her about Bournes quick departure (see above)

Dr Trevor removed the bone that Bourne missed removing and he did it with care.

I told him about the swelling and the sore/blister on the upper lip and what I was told by Bourne “the slow, older persons, healing process” I told him of Bourne’s exclaiming “”SURPRISE”” before he jabbed a needle in my gums. Dr Trevor shook his head. I also told him that the pain of the process ie swelling of the face and gums were getting a little better but the throbbing was getting worse. and that my lips would burn. When I wore the partial (this went without any solution or suggestion as to what it could be so ….I thought that maybe my lips were just chapped, which they were not.) My extractions were healing but far slower than the bottom extractions and when they eventually did seal off and heal the result was no feeling in them at all, honestly feeling like foreign wood in my mouth, with a continuous throbbing dull pain of quite high intensity across the upper gum, on both sides of the nose: exactly where needles had been thrust in frustration.

In the record, my ‘statement’ about ‘pain getting better’ wasn’t pain getting better at all. It was the swelling that was getting better and going down.

Before leaving the office that day, Brenda told me to “write everything down” as to the experience I had with Bourne so I did as soon as I got home that evening.

I was surprised when Dr Trevor called that very evening (I believe he called from home as he did on several other occasions) because I had never had a dentist call and check up on ANY procedure I have ever had done in my life. (not even after my cancer was removed and I went home…no calls from a doctor!!) My husband spoke with him and told him about the notes I had written down that Brenda asked me to do and said he would bring them in on the post op visit scheduled two days from this day (6/29/2009)on Wednesday, 7/1/2009. Dr Trevor told my husband that he wanted to hear what were in my notes (and to bring the notes to him, not to Brenda) and asked my husband to read the notes to him which my husband did.

After hearing my words from the notes, Dr Trevor said that he wanted me to come in first thing the next day and that he was off work that day but would go in anyway and find an open room.

My copy of the notes written at Brenda’s request… are included here…. but the original notes were not included in the records sent to me by the dental office. I had given them to Dr Trevor personally as he had instructed. I had no idea that dental firm would place my mouth and my health in the hands of albeit, a kind and potentially good dentist, an inexperienced graduate, licensed just days before.

Next Morning: (6/30/2009)

Dr Trevor called very, very early and stated that he was at the dental office and that it wasn’t actually opened yet when my husband stated that it was way too early. I believe the call came in just a little after 7 AM.

I don’t actually remember the exact time that we arrived at the dental office (closer to 9ish am ) but I honestly believe it was way before the time that is on the clinical notes because it was a long talk with Dr Trevor after he was read my notes the night before and I was, at that time, stressed about the whole ordeal and was actually wondering when the throbbing would ever end.

Dr Trevor asked me ‘what did Bourne do” (referring to what had he done already) but I summed it up in 3 words…”he screwed up” and that what I had decided to do , the weighted out decision of having my teeth removed in order to have a nice smile,) looks very bleak because now I have another doctor that has taken over my case telling me the na’s of wearing a partial and that I would be happier with implants and that the “three teeth left was not an Ideal restoration and has a guarded long term prognosis” I asked Dr Trevor then “Why didn’t HE tell me this”…Dr Trevor shook his head and said that he didn’t know.

Dr Trevor states that I left in ‘good spirits’….???

I had stopped crying…..yes….I had just been told that that the plan I had started was not going to work and he was recommending implants. He sidestepped my pain and suffering, which had only just begun. He ignored the complaint and apparently followed instructions. He made no other decisions on his own with admitting his father and the Dr. Bigler consulted with him.

He had told me, after hearing that Bourne had injured me, that my new teeth in his opinion, would never work. He wanted to remove the three remaining teeth. They were left there according to Bourne to have clips on them. Trevor wanted me to change to either a full plate (which he knew I could not do, due to a serious gagging problem) or to get implants, which he knew our budget could not do. Yes I broke down in tears. I just had my teeth removed and then find out it was never going to work?!? My gums were too short, Trevor claimed. Like his, he said.

I guess shock set in.

Next: (7/1/2009)

With each visit I had after the throbbing started, I complained about it and even once stated to Dr Trevor that I was so sorry for complaining about that and he said that I had every reason to complain.

Next: (7/8/2009)

Still throbbing.

Next: (7/24/2009)

Frenectomy

The office never had a code for this procedure or even knew how much to charge. Holly had to ask another Dentist, Dr.Bigler, how much to charge. She stated that Dr. Bigler said that $300.00 sounds about right and she would get the code and put it into their system.

Throbbing.

Next: (7/27/2009)

The throbbing was really bad…..I left the partial out because of the ‘burning and blisters’….that’s the reason not because it made the throbbing worse or not.

I did talk about “pressure” but the pressure I talked about was when I touched the upper lip/nose area and I showed Dr Trevor when I was having the throbbing and also told him that just trying to blow my nose was painful.

Next: (8/3/2009)

Dr Trevor talked about referred pain and showed a picture of the Trigeminal nerves in the jaw and explained how he had gotten the picture from the Internet and that it showed how a tooth in the back could make pain happen near the front. He literally mentioned the actual damaged nerves without considering them, other than a conduit.

Dr Trevor noticed the “bump” (which was a blister from wearing the partial) and states in the notes that “he thinks it is because we performed the frenectomy and it could just be the lip itself adj to the newly created room”

I had been complaining about bumps/blisters/burning long before this surgery but no one paid attention! They did not want to hear how the flipper that was ordered at the last minute was sent to a different lab than the one they normally used. Or, at least Bourne got the message in the hallway to do so.

Dr Trevor talked about going forward and my husband stated that the throbbing situation must be fixed first before we go forward and I agreed.

((Had to go shopping with my granddaughter for things she needed to start college and I didn’t want to go without teeth so I wore the partial during that shopping time which lasted about 5 hours and the burning and blisters became almost unbearable. I asked my granddaughter to take a look and she exclaimed “my goodness grandma, you have a HUGE blister on your top lip and a long red line on your bottom lip”..

I removed the partial as soon as I returned home.

((Got a call from Dr Trevor…..my husband told him of the problem because I told Dr Trevor that my mouth was so sore that it hurt to talk so I told him that my husband wanted to speak with him anyway. My husband stated to Dr Trevor that a plan had to be made…..Dr Trevor said he would consult with his Dad ,Wynn Caffall and Dr Bigler, to see what the plan would be and get back with us.

The next day, a very strong antibiotic was prescribed for me along with purchasing a ‘sinus rinse’ ….The antibiotics cost was almost $50.00!! Then they made up the answer to a sinus problem question and Trevor summed it up as their diagnoses of sinus cavity issues, which according to their fiction, were already there.

The blisters and the burning of the mouth was horrible and the throbbing was continuous.

My husband called again…..the lady at the desk who answered my husband’s call asked Brenda (office manager??? I think…) about me coming in and the lady quoted Brenda as referring to me as their “special patient”.

Next (8/14/2009)

Now….Dr Trevor notices the blisters and the red line even though I hadn’t worn the device in a few days prior to this visit, they were still there. (as a matter of fact, as I write this (August 26th, 2009) there is still a small existing part of the huge blister that has not gone away as of yet.)

How dare this dental practice to state in these records that “they degraded our lab saying they might not have used a good quality acrylic” When in FACT…by Dr Trevor’s own voice mail admits that could be the reason.

Statements claim that Dr Trevor admits to being “stumped” when in fact he said that “we’re all perplexed” and my reply was, “so am I” but my reasoning wasn’t their reason. I was wondering why can’t someone fix this, why can’t someone care enough about the pain I was in, that was growing literally by the day instead of all the back door conferences of guess work between Wynn Caffall, John Bigler as well as the just out of college son, Trevor Caffall: and no treatment for the pain.

The last part written here where Dr Trevor was supposed to have proclaimed about the nasal cavity, I never heard…..In fact,…that was never said in my or my husbands presence.

Looks really funny to me that the beginning of the “Clinical Notes” I received started with something I never said “Pt states periodic nasal sinus problem”

to ……………this which was never said to me or to my husband which was “Dr. said that it seems to be something in the nasal cavity that is not healing well, there is pain just to the touch when gently rubbing with the probe pt. was in lots of pain.”

Why was this put in the record when I never heard it? Why was I not treated for pain?

and also, why were notes taken on 8/19/2009 long after I walked out and after my request for my records were received? After the records were closed as they no longer had the patient.

 The Clinical notes show a total of 19 different dates of “notes Created”, my visits to that office were a total of 18.

 The last entry was on 8/19/2009 by (apparently Dr Trevor but no name mentioned so I don’t know who wrote this) This note was written AFTER the request for my records were received. There was NO contact from anyone from the dental office or Dr Trevor (home or company) between the time I left the office on Friday the 14th of August until 3 calls came in to my home on the morning of the 19th of August.

 One call came in at 11:37 AM to my home # and one message was left… that I am in possession of……

 two minutes later…. a second call was received to my cell phone at 11:39 and no message left…….

 one minute later…….At 11:40 AM the third call came in and another message was left. I have kept both voice messages for my records.

 All from the phone number 480 773-9500

The last visit I had at Canyon Vista I told Dr Trevor that “I have no more tears”…I did have because I tried once again to trust….but the last visit was for the blisters on my upper lip and the burning red line across the bottom lip that was to me, ignored by saying “I’ve never heard anything like that” which my husband told him that we looked up the symptoms …That’s what that visit was for….not about the constant throbbing in my upper jaw, even though it had begun to reach unbearable levels. I became tired of hearing “We’re Perplexed” with the results of each “Perplexed” indecision about my situation didn’t lesson or relieve the pain or stress I had been going through since the extractions. And they never once suggested anything to relieve the pain.

After the dental office received my request for my records, was when Dr Trevor made a diagnosis. I had walked out of that office days prior to his three phone calls. And he misdiagnosed.

Suesie Kent Hempfling

Apache Junction, AZ 85120