Current through Register Vol. 41, No. 3, September 23, 2024
A. A
dentist shall maintain complete, legible, and accurate patient records for not
less than six years from the last date of service for purposes of review by the
board with the following exceptions:
1.
Records of a minor child shall be maintained until the child reaches 18 years
of age or becomes emancipated, with a minimum time for record retention of six
years from the last patient encounter regardless of the age of the
child;
2. Records that have
previously been transferred to another practitioner or health care provider or
provided to the patient or the patient's personal representative pursuant to
§
54.1-2405 of the Code of
Virginia; and
3. Records that are
required by contractual obligation or federal law may need to be maintained for
a longer period of time.
B. Every patient record shall include
documentary evidence of the following:
1.
Patient's name on each page in the patient record;
2. A health history taken at the initial
appointment that is updated (i) when analgesia, sedation, or anesthesia is to
be administered; (ii) when medically indicated; and (iii) at least
annually;
3. Diagnosis and options
discussed, including the risks and benefits of treatment or nontreatment and
the estimated cost of treatment options;
4. Consent for treatment obtained and
treatment rendered;
5. List of
drugs prescribed, administered, or dispensed and the route of administration,
quantity, dose, and strength;
6.
Radiographs, digital images, and photographs clearly labeled with patient name,
date taken, and teeth identified;
7. Notation of each treatment rendered, the
date of treatment and of the dentist, dental hygienist, and dental assistant II
providing service;
8. Duplicate
laboratory work orders that meet the requirements of §
54.1-2719 of the Code of
Virginia, including the address and signature of the dentist;
9. Itemized patient financial records as
required by §
54.1-2404 of the Code of
Virginia;
10. A notation or
documentation of an order required for treatment of a patient by a dental
hygienist practicing under general supervision as required in
18VAC60-21-140 B; and
11. The information required for the
administration of moderate sedation, deep sedation, and general anesthesia
required in
18VAC60-21-260
D.
C. Records shall not
be withheld because the patient has an outstanding financial
obligation.
D. A reasonable
cost-based fee may be charged for copying patient records to include the cost
of supplies and labor for copying documents, duplication of radiographs and
images, and postage if mailing is requested as authorized by §
32.1-127.1:03 of the Code of
Virginia. The charges specified in §
8.01-413 of the Code of Virginia
are permitted when records are subpoenaed as evidence for purposes of civil
litigation.
E. Records shall not be
abandoned or otherwise left in the care of someone who is not licensed by the
board except that, upon the death of a licensee, a trustee or executor of the
estate may safeguard the records until they are transferred to a licensed
dentist, sent to the patients of record, or destroyed.
F. Patient confidentiality must be preserved
when records are destroyed.
Statutory Authority: §
54.1-2400 of the Code of
Virginia.
