Iowa Code r. 481-574.9 - Patient records
(1) Patient
records may be entered or retained electronically or by other means. Dentists
must maintain patient records in a manner consistent with the protection of the
welfare of the patient and comply with the following:
a. Preserve and maintain the confidentiality
of patient records as required by state and federal law.
b. Ensure that all entries into patient
records are permanent, timely, accurate, legible, and easily
understandable.
c. Update and
correct errors in the patient record electronically, or legibly in ink, with no
erasures or white-outs. If incorrect information is placed in the record, cross
out the error with a single nondeleting line and include the initials or other
means of identification for the licensee or registrant who updated the
record.
d. Safeguard the records
from destructive elements.
e.
Maintain a duplicate hard copy or use an unalterable record when electronic
records are kept.
(2)
Dentists will create and maintain dental records for each patient that contain
all of the following:
a. Patient information
that includes the following:
(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.
b. Dental and medical history information
sufficient to support the recommended treatment plan from the patient or the
patient's parent or guardian.
c.
Patient's stated reasons related to oral health when a patient presents with a
chief complaint.
d. Dental records
shall include chronological entries, including dates and descriptions of the
following:
(1) Clinical examination findings,
tests conducted, and a summary of all pertinent diagnoses;
(2) Plan of intended treatment and treatment
sequence;
(3) Services rendered and
any treatment complications;
(4)
All radiographs, study models, and periodontal charting, if
applicable;
(5) Name, quantity, and
strength of all drugs dispensed, administered, or prescribed; and
(6) Name of dentist, dental hygienist, or any
other auxiliary, who performs any treatment or service or who may have contact
with a patient regarding the patient's dental health.
e. Documentation, at a minimum, of informed
consent that includes an overview of the discussion of proposed procedure(s),
treatment options, potential complications and known risks, and patient's
consent to proceed with treatment.
(3) Transfer of records. Upon request of the
patient or patient's legal guardian, the dentist shall furnish copies of the
complete dental records, including copies of the radiographs that are of
diagnostic quality.
a. The dentist may not
refuse to transfer records for any reason, including but not limited to
nonpayment of any fees.
b. The
dentist may charge a nominal fee for duplication of records.
Notes
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