RECORDKEEPING RULES

 

Dentists shall maintain patient records in a manner consistent with the protection of the welfare of the patient. Records shall be legible and easily understandable.

 

Dental Records. Dentists shall maintain dental records on each patient. The records shall contain components specified in the following subparts.

 

Personal Data.

 

1 . Name, date of birth, address and, if a minor, name of parent or guardian. 2. Name and telephone number of person to contact in case of emergency.

 

Dental and Medical History. Dental records shall include information from the patient or the patient's parent or guardian on the patient's dental and medical history. The information shall include a sufficient amount of data to support the recommended treatment plan.

 

Patient's reason for visit. When a patient presents with a chief complaint, dental records shall include the patient's stated oral health care reasons for visiting the dentist.

 

Clinical examination progress notes. Dental records shall include chronological dates of the following:

 

1 .           Description of clinical examination, tests conducted and diagnosis.

2.        Plan of intended treatment.

3.           Description of services rendered and any treatment complications.

4.           Description of all radiographs, study models, and periodontal charting if applicable.

5.        Name of, quantity of, and strength of all drugs dispensed, administered, or

           prescribed.

6.        Name of dentist, dental hygienist, or any other auxiliary, who performs any

           treatment or service or who may have information regarding a patient.

 

Informed consent. Dental records shall include documentation of informed consent which includes discussion of procedure(s), options, potential complications and known risks and patient's consent to proceed with treatment.

 

Retention of records. A dentist shall maintain a patient's dental record for a minimum of five years after the last date of examination, prescribing or treatment. Records for minors shall be maintained for a minimum of one year after the patient reaches the age of majority (18).

 

Electronic recordkeeping. The requirements of the above subparts apply to electronic recordkeeping as well as to recordkeeping by any other means. When electronic records are kept, a dentist shall keep either a duplicate hard copy record or use an unalterable electronic record.