Washington Administrative Code
Title 246 - Health, Department of
PROFESSIONAL STANDARDS AND LICENSING
Chapter 246-815 - Dental hygienists
Section 246-815-164 - Patient record content
Universal Citation: WA Admin Code 246-815-164
Current through Register Vol. 24-18, September 15, 2024
(1) A dental hygienist who treats patients shall maintain legible, complete, and accurate patient records.
(2) The patient record must contain the clinical records and the financial records.
(3) The clinical record must include at least the following information for each entry:
(a) The signature, initials, or electronic
verification of the individual making the entry note;
(b) The identity of who provided treatment if
treatment was provided;
(c) The
date of each patient record entry;
(d) The physical examination findings
documented by subjective complaints, objective findings, an assessment of the
patient's condition, and plan;
(e)
A dental hygiene treatment plan based on the analysis of assessment
findings;
(f) Up-to-date dental
hygiene and medical history that may affect dental hygiene treatment;
(g) A complete description of all
treatment/procedures administered at each visit;
(h) An accurate record of any medication(s)
administered;
(i) Referrals and any
communication to and from any health care provider;
(j) Notation of communication to or from the
patient or minor patient's parent or guardian, including:
(i) Notation of the informed consent
discussion. This is a discussion of potential risk(s) and benefit(s) of
proposed treatment, and alternatives to treatment, including no
treatment;
(ii) Notation of
posttreatment instructions or reference to an instruction pamphlet given to the
patient;
(iii) Notation regarding
patient complaints or concerns associated with treatment, this includes
complaints or concerns obtained in person, by phone call, email, mail, or text;
and
(iv) Termination of
hygienist-patient relationship.
(4) Clinical record entries must not be erased or deleted from the record.
(a)
Mistaken handwritten entries must be corrected with a single line drawn through
the incorrect information. New or corrected information must be initialed and
dated.
(b) If the record is an
electronic record then a record audit trail must be maintained with the record
that includes a time and date, history of deletions, and edits and corrections
to the electronically signed records.
Disclaimer: These regulations may not be the most recent version. Washington 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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