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Dental Records 101: What Should be in the Records?

Written by Duane Tinker (aka the Toothcop)

Items You ABSOLUTELY Need to Include:

Patient Information:

Patient's name, age, contact information, emergency contact.

Date and Time of Visit:

Essential for tracking progress and treatments over time.

Reason for Visit:

Whether it's a regular check-up, a specific complaint, or follow-up treatment.

Vital Signs:

Blood pressure, heart rate, and other relevant metrics.

Medical History:

Updates or changes to their general health, medications, and allergies.

Examination Findings:

What you discover during your oral exam. Gum health, tooth condition, etc.

Diagnosis:

Your professional assessment of the patient's oral health needs.

Treatment Plan:

Procedures planned or undertaken, including alternatives and risks discussed.

Informed Consent:

Documentation that the patient has understood and agreed to the treatment plan.

Radiographs, Photographs, and Models:

Any imaging or models taken, with a note on why they were necessary.

Code out Completed Procedures:

Make sure you correctly code the procedures you provide (and nothing more).

Progress Notes:

Any observations or changes during the course of treatment.

Financial Transactions:

A clear statement of fees charged, payments received, and balance due, if any.

Referrals:

Documentation about consultations with specialists or additional services needed.

Post-treatment Instructions:

Any guidelines or recommendations given to the patient for at-home care.

How Long Should You Retain Patient Records?

Again, every state is different. Keeping these records for at least five years from the last date of treatment is generally the standard. There may be different standards for your state for records of minor patients. For patients who were minors at their last visit, records should be kept for a longer period, often until the patient turns 21, although this can vary by state. Familiarize yourself with your state’s regulation. 


How to Handle Requests for Records

Timeframe:
Be sure to provide requested records within 30 calendar days (15 business days in Texas). If a patient requests them, as per the HIPAA regulations. NOTE: some states have more strict timelines. Know your state’s regulations. Also know this is a favorite issue for enforcement action by OCR (HIPAA police). Herein fail not to comply with providing patient records in a timely manner. Make sure you can prove you complied. 

Fees:
You can charge a reasonable fee for making copies and postage if the records are mailed. Some states have specific rules on how much can be charged, so you should check local regulations. For Texas peeps this is addressed in TSBDE Rule 108.8 (at the bottom of the rule). As a best practice consider waiving fees when providing patients access to their own records. Charging patients for their records is legal, but charging even the slightest bit too much is way more trouble than it’s worth. 

Format:
Records can usually be provided in the format requested by the patient, whether that's paper copies or electronic files. If you provide them electronically, consider using an encrypted email or fileshare program. 

Authorization:
You'll need a signed request or authorization form from the patient or their legal representative to release records to a third party. This is a very specific form with specific requirements. Review your form to make sure it meets the specific requirements of the law. Use the form appropriately. Do not have every patient sign a blank version of this form for ‘just in case’. 

Hope this clears things up for you and your team. It’s always better to know the rules than to wing it and face the consequences later. Keep smiling and keep those pearly whites shining!


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