Fla. Admin. Code Ann. R. 64B5-17.002 - Written Dental Records; Minimum Content; Retention

A dentist shall maintain patient dental records in a legible manner and with sufficient detail to clearly demonstrate why the course of treatment was undertaken.

(1) Dental Record: The dental record shall contain sufficient information to record each patient/dentist in person or teledentistry encounter, identify the patient, support the diagnosis, identify and justify the treatment and document the course and results of treatment accurately, by including, at a minimum, patient histories; X-rays (if taken); examination results; test results; records of drugs prescribed, dispensed, or administered; reports of consultation or referrals; identification of all treatments and procedures performed and when they were performed; and copies of records or reports or other documentation obtained from health care practitioners at the request of the dentist and relied upon by the dentist in determining the appropriate treatment of the patient.

(2) Record Alterations: Any additions, corrections, modifications, annotations, or alterations (hereinafter "change") to the original dental record entry must be clearly noted as such and must include the date when the change was made, must be initialed by the person making the change, and must have an explanation for the change. An original entry to the record cannot be partially or wholly removed. Rather, to represent the deletion of a record entry, the entry must be struck through where it will remain legible. A change made on the same date of the original entry must also include the time of change.

(3) Record Transfer or Release: Whenever patient records are released or transferred, the dentist releasing or transferring the records shall maintain either the original records or copies thereof and a notation shall be made in the retained records indicating to whom the records were released or transferred and the authority for such release. Transfer of records in a multidentist practice office shall be done and documented in strict accordance with Section 466.018, F.S.

(4) Record Retention Period: A dentist shall maintain the written dental record of a patient for a period of at least four (4) years.

(a) The four (4) year retention period shall be calculated from the date the patient was last examined or treated by the dentist.

(b) Upon the death of the dentist, the retention provisions of Rule 64B5-17.001, F.A.C., are controlling.

(5) Appointment Book: Each dentist shall retain a copy of each entry in his or her patient appointment book or such other log, calendar, book, file or computer data, used in lieu of an appointment book, for a period of no less than four (4) years from the date of each entry thereon.

(6) Dentist of Record: All records that are required by this rule and any other patient record shall be properly annotated to identify the dentist of record. The dentist of record is the dentist who:

(a) Is identified and noted in the patient record as the dentist of record;

(b) Provides a specific treatment or service and is noted in the patient record as the dentist of record for that treatment or service;

(c) If there has been more than one provider of treatment, is the dentist who places the final restoration, does the surgical procedure, makes the diagnosis or finishes the service or procedure in question, or

(d) If the dentist of record is not identifiable, then the owner of the dental practice in which the patient was treated is the dentist of record.

(7) Owner of Dental Practice: All dental records required by this rule and any additional records maintained in the course of practicing dentistry shall be the property of the owner dentist of the dental practice in which the dental patient is seen or treated and the owner dentist shall be ultimately responsible for all record keeping requirements set forth by statute or rule.

(a) The owner dentist is responsible for the records of patients seen or treated by any employee, associate, or visiting dentist.

(b) Multiple owners are severally and equally responsible for the records of patients seen or treated with the dental practice of that dental group.

(c) A lessor or owner dentist is not responsible for the records of an independent dentist who is merely leasing or renting space or staff services for the operation of a separate dental practice within the owner dentist's physical facility.

(8) Electronic Dental Records: Patient records may be kept in an electronic format, provided that the dentist maintains a back-up copy of information stored in the back-up data processing system using disk, tape, or other secure electronic back-up system, onsite or off-site, as long as the back-up system is updated in a time frame that does not exceed seventy-two hours (72 hrs.), to assure that data is not lost due to system failure. Any electronic data system must be capable of producing a hard copy on lawful demand in accordance with and pursuant to federal or state laws and rules.

Notes

Fla. Admin. Code Ann. R. 64B5-17.002

Rulemaking Authority 466.004(4) FS. Law Implemented 456.057, 456.058, 466.028(1)(m), 466.018(4) FS.

New 10-8-85, Formerly 21G-17.02, Amended 10-28-91, Formerly 21G-17.002, Amended 11-22-93, Formerly 61F5-17.002, 59Q-17.002, Amended 11-15-99, 4-22-03, 3-14-13, Amended by Florida Register Volume 41, Number 082, April 28, 2015 effective 5/14/2015, Amended by Florida Register Volume 42, Number 066, April 5, 2016 effective 4/17/2016, Amended by Florida Register Volume 49, Number 202, October 17, 2023 effective 10/30/2023.

New 10-8-85, Formerly 21G-17.02, Amended 10-28-91, Formerly 21G-17.002, Amended 11-22-93, Formerly 61F5-17.002, 59Q-17.002, Amended 11-15-99, 4-22-03, 3-14-13, 5-14-15, 4-17-16, 10-30-23.