From the Winter 2017 Journal of the Colorado Dental Association
As regularly shared with CDA members over the last year, the Colorado Dental Board extensively revised state rules regulating dentists. Nearly all dental board rules were reviewed in this process, including recordkeeping rules for dental practices (Rule IX). These new rules took effect on June 30, 2016.
While laws and rules can seem like tedious topics, they have a major impact on your day-to-day practice. It’s important to be informed of their effects.
What are the most important things to know about the new (and continuing) recordkeeping rules? And what will have the biggest impact on your practice? Here are some highlights.
- Records retention: All patient records must be kept for seven years after the patient’s last dental visit (or seven years after the patient turns 18 for all pediatric patients).
- Patient records requests: A patient must submit a signed and dated request in order to inspect or obtain a copy of his/her record. The dental office must acknowledge this record request in writing. A patient must be given a copy of the requested record or allowed to inspect the record within seven calendar days. A patient cannot be charged for the inspection of records and may only be charged the actual costs of reproduction (no labor fees may be included) and postage, when applicable. The dental office may supply a written interpretation of non-written records that cannot be reproduced without special equipment (radiographs, diagnostic casts, etc.) or the patient may pay the actual cost of reproduction of these records. If the office maintains electronic records, an electronic copy of the patient’s record must be provided if requested. Records cannot be withheld for past due fees. Past providers who no longer work at a dental office may request copies of the clinical records of patients they treated. The records release requirements for patients also apply to former treatment providers.
- Records destruction: When a dental office plans to dispose of records, affected patients must be notified by email, mail or publication at least 60 days prior to destruction. Affected patients must have at least 30 days to claim their records, and these records must be provided at no charge. Notice by publication must be placed in both a major and community newspaper (one day per week for four consecutive weeks). The posting can be done either in print or online. HIPAA compliant destruction methods are identified for both paper and electronic records.
- Clinical documentation requirements:
- Examinations: Rule IX was revised to identify specific elements that must be documented as part of comprehensive, limited, periodic and periodontal exams.
- General procedures: A patient’s record must document that recommended treatment as well as risks, benefits, alternatives and prognosis were discussed. The patient’s treatment election or declination must also be documented, as well as any patient selection that deviates from the dentist’s recommendation. Verbal consent for treatment must be recorded.
- Root canals: Documentation of the use of a rubber dam is required.
- Anesthesia: Patient record requirements are listed in Rule XIV (G).
- Pediatric case management and protective stabilization: Patient record requirements are listed in Rule XV (A)(1) and Rule XV (E).
- Lasers: Patient record requirements are listed in Rule XXIV (F).
- Referrals: All specialist referrals must be noted in the record.
- Prescriptions: Prescribing requirements for prescription drugs as well as controlled substances are detailed in the rule, as well as requirements for prescription documentation in patient records. Dentists who administer and dispense controlled substance prescriptions from their offices are subject to additional DEA requirements listed, including patient record documentation, maintenance of an office inventory log, storage and security requirements, and drug disposal restrictions. All records relegated to controlled substances must be legible, comprehensive and organized in an accurate and objective manner.
- Exceptions process: If any documentation requirements cannot be met, the dentist must record the rationale for why the requirement was not met in the patient record.
- Identification of Provider: Records must note which dental office employee performed each procedure for a patient and the dentist who supervised procedures requiring supervision, as applicable.
Read or download a copy of the Dental Practice Act and rules mentioned in the article.