Minn. R. agency 125, ch. 3100, RECORD KEEPING, pt. 3100.9600 - RECORD KEEPING

Subpart 1. Definitions.

For the purposes of this part, "patient" means a natural person who has received dental treatment from a provider. In the case of a minor who has received dental treatment pursuant to Minnesota Statutes, sections 144.341 to 144.347, the patient includes a parent or guardian.

Subp. 2. Dental records.

Dentists shall maintain dental records on each patient. The records must contain the components specified in subparts 3 to 10.

Subp. 3. Personal data.

At a minimum, dental records must include the patient's:

A. name;

B. address;

C. date of birth;

D. parent's or guardian's name, if the patient is a minor;

E. emergency contact; and

F. insurance information.

Subp. 4. Patients reasons for visit.

When a patient presents with a chief complaint, dental records must include the patients stated oral health care reasons for visiting the dentist.

Subp. 5. Dental and medical history.

Dental records must include information from the patient or the patients parent or guardian on the patients dental and medical history. The information must include a sufficient amount of data to support the recommended treatment plan. The dental and medical history must be updated to reflect the current status of the patient.

Subp. 6. Clinical examinations.

When a limited examination is performed, items A to C pertain only to the area treated. When a comprehensive examination is performed, dental records must include:

A. recording of existing oral health care status;

B. any radiographs and photographs used with the date the image is taken and the patient's name; and

C. the results of any other diagnostic aids used.

Subp. 7. Diagnosis.

Dental records must include a diagnosis.

Subp. 8. Treatment plan.

Dental records must include an agreed upon written and dated treatment plan except for routine dental care. The treatment plan must be updated to reflect the current status of the patient's oral health and treatment.

Subp. 9. Informed consent.

Dental records must include a notation that:

A. the dentist, advanced dental therapist, dental therapist, dental hygienist, or licensed dental assistant discussed with the patient the treatment options and the prognosis, benefits, and risks of each treatment that is within the scope of practice of the respective licensee; and

B. the patient has consented to the treatment chosen.

Subp. 10. Progress notes.

Patient records must include a chronology of the patient's progress throughout the course of all treatment. All written progress notes must be legible and written in ink. The chronology must include:

A. all treatment provided;

B. all medications and anesthetics used ;

C. all dental materials placed;

D. the treatment provider by license number, name, or initials;

E. when applicable, the identity of the collaborating dentist authorizing treatment by license number; and

F. administration information for nitrous oxide inhalation analgesia, including indication for use, dosage, duration of administration, posttreatment oxygenation period prior to discharge, and patient status at discharge.

Subp. 11. Amendments to records.

If incorrect information is placed in a written record, it must be amended by crossing out with one single line and initialed by the provider. The provider initialing the record must identify who the provider is on the written record. In an electronic health record, an amendment to the record must be electronically time and date stamped by the provider.

Subp. 12. Retention of records.

A. For an adult patient with an active file, the dentist must maintain the patient's entire dental record. For an adult patient with an inactive file, the dentist must maintain the patient's dental records for at least seven years beyond the patient's last date of treatment by the dentist.

B. For a minor patient with an active file, the dentist must maintain the patient's entire dental record. For a minor patient with an inactive file, the dentist must maintain the patient's dental records until the patient is 25 years old.

Subp. 13. Transfer of records.

A patient's dental records must be transferred according to Minnesota Statutes, sections 144.291 to 144.298, irrespective of the status of the patient's account. Digital radiographs shall be transferred by compact or optical disc or electronic communication. All transferred film or digital radiographs must reveal images of diagnostic quality.

Subp. 14. Electronic record keeping.

A. The requirements of subparts 1 to 13 apply to electronic record keeping as well as to record keeping by any other means.

B. When electronic records are kept, a dentist must use an unalterable electronic record.

Notes

Minn. R. agency 125, ch. 3100, RECORD KEEPING, pt. 3100.9600

21 SR 1730; L 2007 c 147 art 10 s 15; 35 SR 459; 36 SR 738; 37 SR 184921 SR 1730; L 2007 c 147 art 10 s 15; 35 SR 459; 36 SR 738; 37 SR 1849; 39 SR 1455; 43 SR 507; 43 SR 295; 43 SR 507 46 SR 908 46 SR 1308 48 SR 1089

Statutory Authority: MS s 144.335; 150A.04; 150A.08