Current through Register 1531, September 27, 2024
(1)
Content of Patient
Record. Patient records include, but are not limited to, dental
charts, photographs, patient histories, examination and test results,
diagnoses, treatment plans, progress notes, anesthesia charts, orthodontic
models, prescriptions, radiographs, patient consents, and billing
records.
(2)
Confidentiality of Patient Records. All patient
records including, but not limited to, dental charts, photographs, patient
histories, examination and test results, diagnoses, treatment plans, progress
notes, anesthesia charts, orthodontic models, prescriptions, radiographs,
patient consents, and billing records of any patient treated shall be
maintained in a manner that ensures confidentiality and access for patients and
authorized practitioners who may wish to obtain a copy of patient
records.
(3)
Record
Retention Requirement. The licensee shall maintain a patient's
original dental record and original radiographs (x-rays) for a minimum of seven
years from the date of the last patient treatment. In addition, the patient
record of a minor shall be retained for a minimum of seven years from the date
of the last patient treatment or three years from when the patient has reached
the age of majority, whichever is later.
(4)
Availability of Dental
Records.
(a)
Request
for Copy of Dental Record. The licensee shall provide upon request
by a patient or another specifically authorized person, a complete copy of the
patient's dental record in accordance with M.G.L. c. 112, § 12CC. A copy
of the patient record, including radiographs, shall be provided within a
reasonable amount of time not to exceed 30 calendar days from the date of the
request. The licensee may charge a reasonable fee for the expense of providing
a patient's dental record, not to exceed the cost of either labor and/or
materials incurred in the copying of the patient record, radiographs and
models. The licensee shall not require payment for dental services rendered as
a condition of providing a copy of the dental record. A dentist may offer to
provide the patient with a summary of the patient's record, but the summary
shall not be in lieu of the complete patient record if requested.
(b)
Treatment in a School
Setting. Where consent has been granted by the patient or legal
representative, a copy of the patient's Information Sheet or other written
summary of the screening, examination, or treatment shall be provided to the
official designated by the school.
(c)
Treatment in a Nursing Home
or Residential Treatment Facility. A copy of the patient's
information sheet or other written summary of the screening, examination, or
treatment shall be provided to the official designated by the facility or
institution and shall be made part of the patient record maintained by the
nursing home or residential facility.
(d) If the licensee dies and the practice is
closed, the estate may notify patients treated within the two years prior to
the date of passing. Said notice shall inform patients of how they may obtain a
copy of their patient record, including radiographs. Notice may be by a written
letter to each patient, by electronic notice, public notice in the appropriate
newspaper, and/or by other means which is widely disseminated. A copy of said
notice must be submitted to the Board upon issuance and/or
publication.
(e) Electronic patient
records shall comply with the requirements of 234 CMR 5.13 and
5.14
and shall be unalterable and producible in paper form upon request.
