49 Pa. Code § 33.209 - Preparing, maintaining and retaining patient records
(a) A dentist shall maintain a dental record
for each patient which accurately, legibly and completely reflects the
evaluation and treatment of the patient. A patient dental record shall be
prepared and maintained regardless of whether treatment is actually rendered or
whether a fee is charged. The record shall include, at a minimum, the
following:
(1) The name and address of the
patient and, if the patient is a minor, the name of the patient's parents or
legal guardian.
(2) The date of
each patient visit.
(3) A
description of the patient's complaint, symptoms and diagnosis.
(4) A description of the treatment or service
rendered at each visit and the identity of the person rendering it.
(5) Information as required in §
33.208 (relating to prescribing,
administering and dispensing medications) and this section with regard to
controlled substances or other medications prescribed, administered or
dispensed.
(6) The date and type of
radiographs taken and orthodontic models made, as well as the radiographs and
models themselves. Notwithstanding this requirement, the dentist may release
orthodontic models to the patient. This transaction shall be memorialized on a
form which is signed by the patient. The signed form shall become part of the
patient's record.
(7) Information
with regard to the administration of local anesthesia, nitrous oxide/oxygen
analgesia, conscious sedation, deep sedation or general anesthesia. This shall
include results of the preanesthesia physical evaluation, medical history and
anesthesia procedures utilized.
(8)
The date of each entry into the record and the identity of the person providing
the service if not the dentist of record-for example, dental hygienist,
expanded function dental assistant, dental assistant, and the
like.
(b) A patient
dental record shall be retained by a dentist for a minimum of 5 years from the
date of the last dental entry.
(c)
Within 30 days of receipt of a written request from a patient or a patient's
parents or legal guardian if the patient is a minor, an exact copy of the
patient's written dental record, along with copies of radiographs and
orthodontic models, if requested, shall be furnished to the patient or to the
patient's new dentist. This service shall be provided either gratuitously or
for a fee reflecting the cost of reproduction.
(d) The obligation to transfer records under
subsection (c) exists irrespective of a patient's unpaid balance for dental
services or for the cost of reproducing the record.
(e) Dentists shall provide for the
disposition of patient records in the event of the dentist's withdrawal from
practice, incapacity or death in a manner that will ensure their availability
under subsection (c).
(f) The
components of a patient dental record that are prepared by a dentist or an
agent and retained by a health care facility regulated by the Department of
Health or the Department of Public Welfare shall be considered a part of the
patient dental record required to be maintained by a dentist, but shall
otherwise be exempt from subsections (a)-(e). The components of a patient
dental record shall contain information required by applicable Department of
Health and Department of Public Welfare regulations-see, for example, 28 Pa.
Code §141.26 (relating to patient dental records)-and health care facility
bylaws.
(g) This section does not
restrict or limit the applicability of recordkeeping requirements in
§§
33.207 and
33.208 (relating to prescribing,
administering and dispensing controlled substances; and prescribing,
administering and dispensing medications).
(h) A dentist's failure to comply with this
section will be considered unprofessional conduct and will subject the
noncomplying dentist to disciplinary action as authorized in section 4.1(a)(8)
of the act (63 P. S. §
123.1(a)(8)).
Notes
The provisions of this § 33.209 amended under sections 3(c) and 11.2(a) of the Dental Law (63 P. S. §§ 122(o) and 130c(a)).
This section cited in 49 Pa. Code § 33.340 (relating to duties of dentists who are unrestricted permitholders); and 49 Pa. Code § 33.340a (relating to duties of dentists who are restricted permit I holders); and 49 Pa. Code § 33.340b (relating to duties of dentists who are restricted permit II holders).
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