Quick Tips for the Dental Office
}
Maintaining & Retaining Patient Records
The Pennsylvania State Board of Dentistry has very specific regulations for preparing , maintaining and retaining patient records .
Record Maintenance
▶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 .
▶Records must be accurate , legible and comprehensive . ▶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 entering information into the record .
• 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 .