licensee shall have prepared and maintained an accurate and legible record for
each person receiving dental services, regardless of whether any fee is
charged. The record shall contain the name of the licensee rendering the
service and include:
(a) Name and address and,
if a minor, name of guardian;
Date description of examination and diagnosis;
(c) An entry that informed consent has been
obtained and the date the informed consent was obtained. Documentation may be
in the form of an acronym such as "PARQ" (Procedure, Alternatives, Risks and
Questions) or "SOAP" (Subjective Objective Assessment Plan) or their
(d) Date and
description of treatment or services rendered;
(e) Date, description and documentation of
informing the patient of any recognized treatment complications;
(f) Date and description of all radiographs,
study models, and periodontal charting;
(g) Health history; and
(h) Date, name of, quantity of, and strength
of all drugs dispensed, administered, or prescribed.
(2) Each licensee shall have prepared and
maintained an accurate record of all charges and payments for services
including source of payments.
Each licensee shall maintain patient records and radiographs for at least seven
years from the date of last entry unless:
The patient requests the records, radiographs, and models be transferred to
another licensee who shall maintain the records and radiographs;
(b) The licensee gives the records,
radiographs, or models to the patient; or
(c) The licensee transfers the licensee's
practice to another licensee who shall maintain the records and
dental implant is placed the following information must be given to the patient
in writing and maintained in the patient record:
(a) Manufacture brand;
(b) Design name of implant;
(c) Diameter and length;
(d) Lot number;
(e) Reference number;
(f) Expiration date;
(g) Product labeling containing the above
information may be used in satisfying this requirement.
(5) When changing practice locations, closing
a practice location or retiring, each licensee must retain patient records for
the required amount of time or transfer the custody of patient records to
another licensee licensed and practicing dentistry in Oregon. Transfer of
patient records pursuant to this section of this rule must be reported to the
Board in writing within 14 days of transfer, but not later than the effective
date of the change in practice location, closure of the practice location or
retirement. Failure to transfer the custody of patient records as required in
this rule is unprofessional conduct.
(6) Upon the death or permanent disability of
a licensee, the administrator, executor, personal representative, guardian,
conservator or receiver of the former licensee must notify the Board in writing
of the management arrangement for the custody and transfer of patient records.
This individual must ensure the security of and access to patient records by
the patient or other authorized party, and must report arrangements for
permanent custody of patient records to the Board in writing within 90 days of
the death of the licensee.
Or. Admin. R. 818-012-0070
DE 9-1984, f. & ef.
5-17-84; DE 1-1988, f. 12-28-88, cert. ef. 2-1-89, DE 1-1989, f. 1-27-90, cert.
ef. 2-1-90; Renumbered from 818-011-0060; DE 1-1990, f. 3-19-90, cert. ef.
4-2-90; OBD 7-2001, f. & cert. ef. 1-8-01;
2-2016, f. 11-2-16, cert. ef.
2-2019, amend filed 10/29/2019, effective
1-2021, amend filed 11/08/2021, effective
Statutory/Other Authority: ORS 679
Statutes/Other Implemented: ORS 679.140(1)(e) &