Current through Reg. 50, No. 13; March 28, 2025
(a) The term
dental records includes, but is not limited to: identification of the
practitioner providing treatment; medical and dental history; limited physical
examination; oral pathology examination; radiographs; dental and periodontal
charting; diagnoses made; treatment plans; informed consent statements or
confirmations; study models, casts, molds, and impressions, if applicable;
cephalometric diagrams; narcotic drugs, dangerous drugs, controlled substances
dispensed, administered or prescribed; anesthesia records; pathology and
medical laboratory reports; progress and completion notes; materials used;
dental laboratory prescriptions; billing and payment records; appointment
records; consultations and recommended referrals; and post treatment
recommendations.
(b) A Texas dental
licensee practicing dentistry in Texas shall make, maintain, and keep adequate
dental records for and upon each dental patient for reference, identification,
and protection of the patient and the dentist. Records shall be kept for a
period of not less than five years from the last date of treatment by the
dentist. If a patient was younger than 18 years of age when last treated by the
dentist, the records shall be maintained by the dentist until the patient
reaches age 21 or for five years from the date of last treatment, whichever is
longer. Dentists shall retain records for a longer period of time when mandated
by other federal or state statute or regulation. Records must include
documentation of the following:
(4) Vital signs, including, but not limited
to, blood pressure and heart rate when applicable in accordance with §
108.7 of this title (relating to
Minimum Standard of Care, General); and
(5) If not recorded, an explanation why vital
signs were not obtained.
(c) Further, records must include
documentation of the following when services are rendered:
(1) Written review of medical history and
limited physical evaluation;
(2)
Findings and charting of clinical and radiographic oral examination:
(A) Documentation of radiographs taken and
findings deduced from them, including radiograph films or digital
reproductions.
(B) Use of
radiographs, at a minimum, should be in accordance with ADA
guidelines.
(C) Documentation of
the findings of a tactile and visual examination of the soft and hard tissues
of the oral cavity;
(4) Treatment plan,
recommendation, and options;
(6) Medication
and dosages given to patient;
(8) Written informed
consent that meets the provisions of §
108.7(7) of this
title;
(9) The dispensing,
administering, or prescribing of all medications to or for a dental patient
shall be made a part of such patient's dental record. The entry in the
patient's dental record shall be in addition to any record keeping requirements
of the DPS or DEA prescription programs;
(10) All records pertaining to Controlled
Substances and Dangerous Drugs shall be maintained in accordance with the Texas
Controlled Substances Act;
(11)
Confirmable identification of provider dentist, and confirmable identification
of person making record entries if different from provider dentist;
(12) When any of the items in paragraphs (1)
- (11) of this subsection are not indicated, the record must include an
explanation why the item is not recorded.
(d) Dental records are the sole property of
the dentist who performs the dental service. However, ownership of original
dental records may be transferred as provided in this section. Copies of dental
records shall be made available to a dental patient in accordance with this
section.
(e) A dentist who leaves a
location or practice, whether by retirement, sale, transfer, termination of
employment or otherwise, shall maintain all dental records belonging to him or
her, make a written transfer of records to the succeeding dentist, or make a
written agreement for the maintenance of records.
(1) A dentist who continues to maintain the
dental records belonging to him or her shall maintain the dental records in
accordance with the laws of the State of Texas and this chapter.
(2) A dentist who enters into a written
transfer of records agreement shall notify the State Board of Dental Examiners
in writing within fifteen (15) days of a records transfer agreement. The
notification shall include, at a minimum, the full names of the dentists
involved in the agreement, include the locations involved in the agreement, and
specifically identify what records are involved in the agreement. The agreement
shall transfer ownership of the records. A transfer of records agreement may be
made by agreement at any time in an employment or other working relationship
between a dentist and another entity. Such transfer of records may apply to all
or any part of the dental records generated in the course of the relationship,
including future dental records. A dentist who assumes ownership of the records
pursuant to this paragraph shall maintain the records in a manner consistent
with this section and is responsible for complying with subsections (f) and (g)
of this section.
(3) A dentist who
enters into a records maintenance agreement shall notify the State Board of
Dental Examiners within fifteen (15) days of such event. The notification shall
include the full names of the dentists involved in the agreement, the locations
involved in the agreement, and shall identify what records are involved in the
agreement. A maintenance agreement shall not transfer ownership of the dental
records, but shall require that the dental records be maintained in accordance
with the laws of the State of Texas and the Rules of the State Board of Dental
Examiners. The agreement shall require that the dentist(s) performing the
dental service(s) recorded in the records have access to and control of the
records for purposes of copying and recording. The dentist transferring the
records in a records maintenance agreement shall maintain a copy of the records
involved in the records maintenance agreement. Such an agreement may be made by
written agreement by the parties at any time in an employment or other working
relationship between a dentist and another entity. A records maintenance
agreement may apply to all or any part of the dental records generated in the
course of the relationship, including future dental records.
(f) Dental records shall be made
available for inspection and reproduction on demand by the officers, agents, or
employees of the State Board of Dental Examiners. The patient's privilege
against disclosure does not apply to the Board in a disciplinary investigation
or proceeding under the Dental Practice Act. Copies of dental records submitted
to the Board on demand of the officers, agents, or employees of the Board shall
be legible and all copies of dental x-rays shall be of diagnostic quality.
Non-diagnostic quality copies of dental x-rays and illegible copies of patient
records submitted to the Board shall not fulfill the requirements of this
section.
(g) A dentist shall
furnish copies of dental records to a patient who requests his or her dental
records. At the patient's option, the copies may be submitted to the patient
directly or to another Texas dental licensee who will provide treatment to the
patient. Requested copies, including radiographs, shall be furnished within 30
days of the date of the request. The copies may be withheld until copying costs
have been paid. Records shall not be withheld based on a past due account for
dental care or treatment previously rendered to the patient. Copies of dental
records submitted in accordance with a request under this section shall be
legible and all copies of dental x-rays shall be of diagnostic quality.
Non-diagnostic quality copies of dental x-rays shall not fulfill the
requirements of this section.
(1) A dentist
providing copies of patient dental records is entitled to a reasonable fee for
copying which shall be no more than $25 for the first 20 pages and $0.15 per
page for every copy thereafter.
(2)
Fees for radiographs, which if copied by an radiograph duplicating service, may
be equal to actual cost verified by invoice.
(3) Reasonable costs for radiographs
duplicated by means other than by a radiograph duplicating service shall not
exceed the following charges:
(A) a full
mouth radiograph series: $15.00;
(B) a panoramic radiograph: $15.00;
(C) a lateral cephalometric radiograph:
$15.00;
(D) a single extra-oral
radiograph: $5.00;
(E) a single
intra-oral radiograph: $5.00; and
(4) State agencies and institutions will
provide copies of dental health records to patients who request them following
applicable agency rules and directives.
