Tenn. Comp. R. & Regs. 0460-02-.12 - DENTAL RECORDS

(1) Purposes - The purposes of these rules are:

(a) To recognize that dental records are an integral part of the practice of dentistry as defined in T.C.A. § 63-5-108.

(b) To give dentists, their professional and non-professional staff, and the public direction about the content, transfer, retention, and destruction of those records.

(c) To recognize that a distinction exists between a dentist's records for a patient receiving services in the dentist's office and those records created by the dentist for that patient for purposes of services provided in a hospital as defined by T.C.A. § 68-11-302(4) and that the distinction exists regardless of the fact that the dentist may also be an employee of the hospital or of a dental group employed or owned by the hospital.

(2) Conflicts - As to dental records, these rules should be read in conjunction with the provisions of T.C.A. §§ 63-2-101 and 102, and are not intended to conflict with those statutes in any way. Those statutes, along with these rules, govern the subjects that they cover in the absence of other controlling state or federal statutes or rules to the contrary.

(3) Applicability - These rules regarding dental records shall apply only to those records, the information for which was obtained by dentists or their professionally licensed employees, or those over whom they exercise supervision, for purposes of services provided in any clinical setting other than those provided in a hospital as defined by T.C.A. § 68-11-302(4), a hospital emergency room or hospital outpatient facility.

(4) Dental Records -

(a) Duty to Create and Maintain Dental Records - As a component of the standard of care and of minimal competency a dentist must cause to be created and cause to be maintained a dental record for every patient for whom he or she, and/or any of his or her professionally licensed or registered supervisees, performs services or provides professional consultation.

(b) Duty to Release Dental Records - A dentist shall not withhold records for non-payment of current or prior dental services.

(c) Notice - Anywhere in these rules where notice is required to be given to patients of any dentist, that notice shall be required to be issued within thirty (30) days of the date of the event that triggers the notice requirement, and may be accomplished by public notice.

(d) Distinguished from Hospital Dental Records - The dental records covered by these rules are separate and distinct from those records generated for the patient by the dentist during the course of providing dental services for the patient in a hospital as defined by T.C.A. § 68-11-302(4) regardless of the fact that the dentist may also be an employee of the hospital or of a dental group employed or owned by the hospital.

1. The provisions of T.C.A. Title 68, Part 11, Chapter 3 govern dental records generated in a hospital as defined by T.C.A. § 68-11-302(4).

2. The dental records covered by these rules are those:

(i) That are created prior to the time of the patient's admission to, or confinement and/or receipt of services in, a hospital as defined by T.C.A. § 68-11-302(4), hospital emergency room and/or hospital outpatient facility, and/or

(ii) That are created after the patient's discharge from a hospital as defined by T.C.A. § 68-11-302(4), hospital emergency room or hospital outpatient facility.

(iii) That are created during the practice of dentistry as defined by T.C.A. § 635-108 outside of a hospital as defined by T.C.A. § 68-11-302(4), hospital emergency room or hospital outpatient facility.

3. Even though the records covered by these rules may, of necessity, reference provision of services in the hospital setting and the necessary initial work-up and/or follow-up to those services, that does not make them "hospital records" that are regulated by or obtainable pursuant to T.C.A. Title 68, Part 11, Chapter 3.

(e) Content -

1. All dental records, or summaries thereof, produced in the course of the practice of dentistry for all patients, shall include all information and documentation listed in T.C.A. § 63-2-101(c) (2).

2. All dental records, or summaries thereof, produced in the course of the practice of dentistry for all patients, shall include such additional information that is necessary to ensure that a subsequent reviewing or treating dentist can both ascertain the basis for the diagnosis, treatment plan and outcomes, and provide continuity of care for the patient.

3. X-rays and X-ray interpretations are considered to be part of the dental records.

4. At a minimum, all dental patient records shall include:

(i) A charting of the patient's teeth conditions.

(ii) Concise description and treatment date for services performed.

(iii) Concise medical history.

(iv) Notation of dates, types, and amounts of pharmaceuticals prescribed or dispensed.

(v) Readable x-rays when required for services rendered.

(f) Transfer -

1. Records of Dentists upon Death or Retirement - When a dentist retires or dies while in practice, patients seen by the dentist in his/her office during the immediately preceding thirty-six (36) months shall be notified by the deceased dentist's or retiring dentist's authorized representative and urged to find a new dentist and be informed that upon authorization, copies of the records will be sent to the new dentist.

2. Records of Dentists upon Departure from a Group - The responsibility for notifying patients of a dentist who departs from a group practice shall be governed by the dentist's employment contract.

(i) Whomever is responsible for that notification must notify patients seen by the dentist in his/her office during the immediately preceding thirty-six (36) months of his/her departure.

(ii) Except where otherwise governed by provisions of the dentist's contract, those patients shall also be notified of the dentist's new address and offered the opportunity to have copies of their dental records forwarded to the departing dentist at his or her new practice. The dental group shall not withhold the dental records of any patient who has authorized their transfer to the departing dentist or any other dentist.

(iii) The choice of dentists in every case should be left to the patient, and the patient should be informed that upon authorization his/her records will be sent to the dentist of the patient's choice.

3. Sale of a Dental Practice - A dentist or the estate of a deceased dentist may sell the elements that comprise his/her practice, one of which is its goodwill, i.e., the opportunity to take over the patients of the seller by purchasing the dentist's patient records. Therefore, the transfer of records of patients is subject to the following:

(i) The dentist (or the estate) must ensure that all patient dental records are transferred to another dentist or entity that is held to the same standards of confidentiality as provided in these rules.

(ii) Patients seen by the dentist in his/her office during the immediately preceding thirty-six (36) months shall be notified that the dentist (or the estate) is transferring the practice to another dentist or entity who will retain custody of their records and that, at their written request, the copies of their records will be sent to another dentist or entity of their choice.

4. Abandonment of Records - For purposes of this section of the rules death of a dentist shall not be considered as abandonment.

(i) It shall be a prima facie violation of T.C.A. § 63-5-124(a) (1) for a dentist to abandon his practice without making provision for the security, or transfer, or otherwise establish a secure method of patient access to their records.

(ii) Upon notification that a dentist in a practice has abandoned his practice and has not made provision for the security, transfer, or establishment of a secure method of patient access to their records, patients should take all reasonable steps to obtain their dental records by whatever lawful means available and should immediately seek the services of another dentist.

(g) Retention of Dental Records - Dental records shall be retained for a period of not less than seven (7) years from the dentist's or his supervisees' last professional contact with the patient except for the following:

1. Dental records for incompetent patients shall be retained indefinitely.

2. Dental records of minors shall be retained for a period of not less than one (1) year after the minor reaches the age of majority or seven (7) years from the date of the dentist's or his supervisees' last professional contact with the patient, whichever is longer.

3. Notwithstanding the foregoing, no dental record involving services which are currently under dispute shall be destroyed until the dispute is resolved.

(h) Destruction of Dental Records -

1. No dental record shall be singled out for destruction other than in accordance with established office operating procedures that are consistent with these rules.

2. Records shall be destroyed only in the ordinary course of business according to established office operating procedures that are consistent with these rules.

3. Records may be destroyed by burning, shredding, or other effective methods in keeping with the confidential nature of the records.

4. When records are destroyed, the time, date and circumstances of the destruction shall be recorded and maintained for future reference. The record of destruction need not list the individual patient dental records that were destroyed but shall be sufficient to identify which group of destroyed records contained a particular patient's dental records.

(5) Violations - Violation of any provision of these rules is grounds for disciplinary action pursuant to T.C.A. §§ 63-5-124(a) (1), and/or (2).

Notes

Tenn. Comp. R. & Regs. 0460-02-.12

Original rule filed October 20, 2003; effective January 3, 2004.

Authority: T.C.A. §§ 4-5-202, 4-5-204, 63-2-101, 63-2-102, 63-5-105, 63-5-108, 63-5-121, and 63-5-124.