Maintaining & Retaining Patient Records
2021
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Quick Tips for the Dental Office
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Record Maintenance
Maintaining & Retaining Patient Records
The Pennsylvania State Board of Dentistry has very specific regulations for preparing, maintaining and retaining patient records.
• 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.
2021