Texas Dentists- Records of the Dentist

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Texas Register

 

TITLE 22

EXAMINING BOARDS

PART 5

STATE BOARD OF DENTAL EXAMINERS

CHAPTER 108

PROFESSIONAL CONDUCT

SUBCHAPTER A

PROFESSIONAL RESPONSIBILITY

RULE §108.8

Records of the Dentist

ISSUE

05/24/2013

ACTION

Final/Adopted

 

Preamble

 

Texas Admin Code Rule

 

 

(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 records of the diagnoses made and the treatments performed 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. Records must include documentation of the following:

            (1) Patients name;

            (2) Date of visit;

            (3) Reason for visit;

            (4) Vital signs, including but not limited to blood pressure and heart rate when       applicable in accordance with §108.7 of this title.

            (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 review of medical exam;

            (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;

            (3) Diagnosis(es);

            (4) Treatment plan, recommendation, and options;

            (5) Treatment provided;

            (6) Medication and dosages given to patient;

            (7) Complications;

            (8) Written informed consent that meets the provisions of §108.7(6) 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.

           

            (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.

            (4) State agencies and institutions will provide copies of dental health records to    patients who request them following applicable agency rules and directives.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on May 9, 2013

TRD-201301857

Glenn Parker

Executive Director

State Board of Dental Examiners

Effective date: May 29, 2013

Proposal publication date: December 28, 2012

For further information, please call: (512) 475-0989