MAINTAINING
& RETAINING
PATIENT
RECORDS
The Pennsylvania State Board
of Dentistry has very specific
regulations for preparing,
maintaining and retaining
patient records.
RECORD MAINTENANCE
n Dentists
must retain a dental record
for patients reflecting their evaluation
and treatment, regardless of whether
treatment is actually rendered or
whether fees are charged.
n Records
must be accurate, legible
and comprehensive.
n Records
must, at a minimum, contain
the following:
– Name and address (and the name
of a minor’s parent or legal guardian).
– Date of visit.
– Description of the patient’s complaint,
symptoms and diagnosis.
– Description of the treatment or
service rendered at each visit and
the identity of the person
administering it.
– Information related to prescribing,
administering and dispensing of
controlled substances and other
medication.
– Date and type of radiographs taken
and orthodontic models made, as
well as the radiographs themselves.
Dentists must maintain written
consent from a patient to release
orthodontic models.
– Information related to the
administration of local anesthesia,
nitrous oxide/oxygen analgesia,
conscious sedation, deep sedation
and general anesthesia, including
the results of pre-anesthesia physical
evaluations, medical history and
anesthesia procedures utilized.
– Date of each entry into the record
and the identity of the person.
– Patient records must be retained
for a minimum of five years from
the date of the last entry.
– There may be additional records
for patient records prepared by a
dentist or an agent and retained
by a health care facility regulated
by the Departments of Health or
Human Services. Consult with
these departments to ascertain
if there are any additional
record-keeping requirements.
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NOV E M B E R/DE CE M BER 2018 | P EN N S YLVA N IA D EN TA L J O UR NAL