Code of Massachusetts Regulations
234 CMR - BOARD OF REGISTRATION IN DENTISTRY
Title 234 CMR 5.00 - REQUIREMENTS FOR THE PRACTICE OF DENTISTRY, DENTAL HYGIENE, AND DENTAL ASSISTING
Section 5.14 - Content of Patient Records

Universal Citation: 234 MA Code of Regs 234.5

Current through Register 1531, September 27, 2024

(1) The patient record shall be a complete record of all patient contact, including, but not limited to, a general description of the patient's medical and dental history and status at time of examination, diagnoses, patient education, treatment plan, referral for specialty treatment, medications administered and prescribed, pre- and post-treatment instructions and information conveyed to the patient pursuant to M.G.L. c. 112, §§ 43 through 53 and 234 CMR 2.00: Purpose, Authority, Definitions.

(2) Patient records shall be legible and clear in meaning to a subsequent examining or treating dentist, the patient, dental auxiliaries or other authorized persons.

(3) At a minimum, a patient's record must include:

(a) Patient Information.
1.Name, address and date of birth of the patient;

2.If the patient is not of the age of majority, the name of the parent or legal representative;

3.If the parents of the minor child are separated or divorced, the name of the custodial parent;

4.If the patient has a legal representative pursuant to 234 CMR 2.00: Purpose, Authority, Definitions, the name and address of the legal representative.

5.Whether the patient is an emancipated minor; and

6.Patient's telephone numbers(s) and electronic mail addresses, except if the patient declines to provide this information.

(b) Medical and Dental History Form. The patient's medical history and dental history shall include, but not be limited to:
1.A review of past and present illnesses, diseases and disabilities;

2.Systemic disease(s) that may affect the oral cavity;

3.Current prescription and non-prescription medications as well as any known drug allergies;

4.Documentation of consultation with the patient's medical physician(s) as appropriate; and

5.Date of the patient's last dental examination, frequency of dental visits, current home care regime and documentation of the patient's primary dental complaint, if any.

6.Upon review of the patient's medical and dental history, any licensee or dental auxiliary in the practice treating the patient shall sign and date the medical and dental history;

7.At each patient visit, the licensee shall inquire and document and initial in the patient record, whether there are any changes in the patient's medical history, including but not limited to, changes in prescription medications.

(c) Record of Dental Examination. Each patient record shall include documentation of the results of a comprehensive clinical examination of the following areas:
1.Head and neck;

2.Radiographic images as necessary and appropriate to facilitate a comprehensive diagnosis of the patient. Radiographs shall be clearly identified with the patient name, date of examination and the name of the dentist;

3.Intra-oral and extra-oral soft tissue examination, including charting of existing restorations and current status of patient's hard and soft tissue;

4.Comprehensive periodontal screening;

5.Oral cancer screening;

6.Examination of the teeth;

7.The results of any other examination performed by the licensee and/or dental auxiliary as necessary and appropriate to facilitate comprehensive diagnoses of the patient's dental status; and

8.Findings which are within or outside of normal limits.

(d) Diagnoses. The patient record shall include written diagnoses of the patient's current dental status based on the evaluation of the patient's medical and dental history, dental clinical examination and radiographic findings.

(e) Treatment Plan. The patient record shall include a written treatment plan describing in detail the proposed treatment. The proposed treatment plan and information regarding estimated fees must be reviewed with the patient prior to the commencement of treatment. The treatment plan shall also include referrals to specialists as necessary. If there is no treatment plan this must be explained and documented in the patient record.

(f) General and Specific Informed Consent. General and/or specific informed consent must be obtained in writing, signed and dated from the patient or legal representative prior to treatment and shall not be obtained fraudulently from a patient under duress or who is not mentally competent, the age of majority or an emancipated minor.
1.General Informed Consent. Each licensee shall obtain from the patient or legal representative general informed consent allowing the licensee to examine, diagnose and treat the patient. Procedures covered by a general informed consent include basic restorative or preventive procedures and permission to bill patient's insurer, if any. The general informed consent may remain in effect until treatment is terminated either by the licensee and/or the patient and the patient is no longer regarded as a patient of record.

2.Specific Informed Consent. Each licensee shall obtain from the patient or the patient's legal representative a specific informed consent allowing the licensee to perform specialized treatment including, but not limited to: administration of anesthesia other than local anesthesia, periodontal, endodontic, orthodontic, prosthetic and oral and maxillofacial procedures, and specialized treatment for pediatric patients, including behavior management techniques.

3.Additional Requirements for Mobile Dental Facilities, Portable Dental Operations, and for Licensees Providing Dental Services in a Public Health Setting. An MDF, PDO as defined in 234 CMR 7.03: Permit M: Application for Mobile Dental Facility Permit and/or Portable Dental Operation or licensee providing dental services in a public health setting shall obtain a signed written consent from the patient or legal representative which conforms to 234 CMR 5.15(3)(f) and also includes the following:
a.An explanation of the scope of services that may be rendered;

b.Notice that the patient may continue to obtain dental care through any other provider;

c.Notice that the treatment of the patient may affect the future rights and benefits due the patient under private insurance, Medicaid, or the children's health insurance program;

d.If applicable, a request for permission to allow the patient's dental insurance carrier to be billed for treatment provided to the patient;

e.If applicable for services rendered in a public health setting, a request for permission to provide the official designated by the school, nursing home, residential facility, or institution with a written summary of the examination; and

f.Information on how the patient or legal representative can contact the MDF or PDO permit-holder, or public health dental services program.

(g) Progress Notes. The patient record shall include written documentation of the treatment provided by the dentist and/or dental auxiliary including but not limited to:
1.Administration of medicines and medicaments including the type, amount, and route of administration;

2.A statement of services provided including patient reaction, if any, during the treatment visit, procedures performed and diagnoses;

3.A description of the pre- and post-treatment instructions including, if applicable, plans for subsequent treatment;

4.Documentation of any referral for specialty treatment, including the name of the specialist the patient is referred to; and

5.A dated written or electronic signature by the dentist or dental auxiliary who treated the patient.

(h) Prosthetic and Orthodontic Prescriptions. All prosthetic and orthodontic prescriptions, whether filled by the licensee or other laboratory, shall be written in accordance with M.G.L. c. 112, § 50, must be in duplicate (copy to be retained by dentist) and include:
1.Name and address of the dental laboratory;

2.Name, initials or identifying number for the patient;

3.Date;

4.Description of the treatment and procedures, including placement of the patient's name and/or identifying patient number;

5.Specification of the type and quality of materials to be used; and

6.Signature and license number of the dentist.

(i) Patient Financial Record. The patient's financial record shall include, but not be limited to, the name of the patient's dental insurer, documentation of fees for treatment and payment schedule, and claims submitted to third parties.

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