North Dakota Administrative Code
Title 20 - State Board of Dental Examiners
Article 20-02 - Dentists
Chapter 20-02-01 - General Requirements
Section 20-02-01-09 - Patient records

Universal Citation: ND Admin Code ยง 20-02-01-09

Current through Supplement No. 394, October, 2024

Dental records must be legible and include a chronology of the patient's progress throughout the course of all treatment and postoperative visits. All entries in the patient record must be dated, initialed, and handwritten in ink or computer printed. Digital radiographs must be transferred by compact or optical disc, electronic communication, or printing on high quality photographic paper. All transferred film or digital radiographs must reveal images of diagnostic quality using proper exposure settings and processing procedures. For purposes of this section:

1. "Patient" means an individual who has received dental care services from a provider for treatment of a dental condition.

2. "Dental record" or "patient's chart" means the detailed history of the physical examination, diagnosis, treatment, patient-related communications, and management of a patient documented in chronological order. The dental record must contain the following components:

a. Personal date to include name, address, date of birth, name of patient's parent or guardian, name and telephone number of a person to contact in case of an emergency, and patient's insurance information.

b. Patient's reason for visit or chief complaint.

c. Dental and physical health history.

d. Clinical examination must include record of existing oral health status, radiographs used, and any other diagnostic aids used.

e. Diagnosis.

f. Dated treatment plan except for routine dental care, such as preventive services.

g. Informed consent must include notation of treatment options discussed with the patient, including prognosis of the treatment plan, benefits and risks of each treatment, and documentation of the treatment the patient has chosen.

h. Corrections of records must be legible, unless electronic and written in ink, and contain no erasures or use of "white-outs". If incorrect information is placed in the record, it must be crossed out with one single line and initialed by the dental health care worker.

i. Progress notes must include a chronology of the patient's progress throughout the course of all treatment and postoperative visits of treatment provided; medications used and materials placed; the treatment provider by name or initials; name of collaborating dentist; administration information of nitrous oxide inhalation or any medication dispensed before, during, or after discharge, and patient status at discharge.

j. Each patient shall have access to health provider information as it pertains to their treating doctor or potential doctors. Any entity utilizing telehealth shall provide upon request of a patient the name of the dentist, telephone number, practice address, and state license number of any dentist who was involved with the provision of services to a patient before or during the rendering of dental services.

3. "Retention of records" means a dentist shall retain a patient's dental record for a minimum of six years after the patient's last examination, prescription, or treatment. Records for minors shall be retained for a minimum of either one year after the patient reaches the age of eighteen or six years after the patient's last examination, prescription, or treatment, whichever is longer. Proper safeguards shall be maintained to ensure safety of records from destructive elements. The requirements of this rule apply to electronic records as well as to records kept by any other means.

General Authority: NDCC 43-28-06

Law Implemented: NDCC 43-28-06, 43-28-18

Disclaimer: These regulations may not be the most recent version. North Dakota may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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