Dental records must be legible and include a chronology of
the patient's progress throughout the course of all treatment and postoperative
visits. All entries in the patient record must be dated, initialed, and
handwritten in ink or computer printed. Digital radiographs must be transferred
by compact or optical disc, electronic communication, or printing on high
quality photographic paper. All transferred film or digital radiographs must
reveal images of diagnostic quality using proper exposure settings and
processing procedures. For purposes of this section:
1. "Patient" means an individual who has
received dental care services from a provider for treatment of a dental
condition.
2. "Dental record" or
"patient's chart" means the detailed history of the physical examination,
diagnosis, treatment, patient-related communications, and management of a
patient documented in chronological order. The dental record must contain the
following components:
a. Personal date to
include name, address, date of birth, name of patient's parent or guardian,
name and telephone number of a person to contact in case of an emergency, and
patient's insurance information.
b.
Patient's reason for visit or chief complaint.
c. Dental and physical health
history.
d. Clinical examination
must include record of existing oral health status, radiographs used, and any
other diagnostic aids used.
e.
Diagnosis.
f. Dated treatment plan
except for routine dental care, such as preventive services.
g. Informed consent must include notation of
treatment options discussed with the patient, including prognosis of the
treatment plan, benefits and risks of each treatment, and documentation of the
treatment the patient has chosen.
h. Corrections of records must be legible,
unless electronic and written in ink, and contain no erasures or use of
"white-outs". If incorrect information is placed in the record, it must be
crossed out with one single line and initialed by the dental health care
worker.
i. Progress notes must
include a chronology of the patient's progress throughout the course of all
treatment and postoperative visits of treatment provided; medications used and
materials placed; the treatment provider by name or initials; name of
collaborating dentist; administration information of nitrous oxide inhalation
or any medication dispensed before, during, or after discharge, and patient
status at discharge.
j. Each
patient shall have access to health provider information as it pertains to
their treating doctor or potential doctors. Any entity utilizing telehealth
shall provide upon request of a patient the name of the dentist, telephone
number, practice address, and state license number of any dentist who was
involved with the provision of services to a patient before or during the
rendering of dental services.
3. "Retention of records" means a dentist
shall retain a patient's dental record for a minimum of six years after the
patient's last examination, prescription, or treatment. Records for minors
shall be retained for a minimum of either one year after the patient reaches
the age of eighteen or six years after the patient's last examination,
prescription, or treatment, whichever is longer. Proper safeguards shall be
maintained to ensure safety of records from destructive elements. The
requirements of this rule apply to electronic records as well as to records
kept by any other means.
Notes
N.D. Admin Code 20-02-01-09
Effective April 1, 2006;
amended effective January 1, 2011.
Amended by
Administrative
Rules Supplement 2021-380, April 2021, effective
4/1/2021.
Amended by
Administrative
Rules Supplement 2022-385, July 2022, effective
7/1/2022.
General Authority: NDCC 43-28-06
Law Implemented: NDCC 43-28-06,
43-28-18
