(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.