SECTION 40-15-83. Patient recordkeeping requirements; penalty.
(A) Dentists shall retain their patient records for at least five years. These minimum recordkeeping periods begin to run from the last date of treatment. After these minimum recordkeeping periods, the records may be destroyed. If a dentist is employed by a corporation or another dentist, the corporation or employing dentist is responsible for maintaining the patient records for a period of five years. The practicing dentist shall have access to these patient records during that period. However, a dentist who works in a nonprofit dental clinic operated solely for the benefit of poor and indigent persons is not required to maintain records for patients seen in that setting. The owner or operator of a nonprofit dental clinic, for at least five years, shall retain patient records for persons treated at the clinic.
(B) A clinic, corporation, or dentist violating subsection (A) is subject to a civil penalty, to be imposed by the board, of up to ten thousand dollars for each violation.
HISTORY: 2000 Act No. 267, § 2.
SECTION 40-15-450. Patient records; health records.
(A) A dentist shall:
(1) maintain timely, legible, accurate, and complete patient records; and
(2) timely provide these records to the patient, another dentist, or a designated medical professional in response to a lawful request for the records by the patient or his legal representative or designee.
(B) A dental practice must have a procedure for initiating and maintaining a health record for every patient evaluated or treated. For procedures requiring patient consent, there must be an informed consent documented in the patient record.
(C) The health record of a patient required under subsection (B) must include appropriate information to:
(1) identify the patient, support the diagnosis, and justify the treatment;
(2) identify the procedure code or suitable narrative description of the procedure; and
(3) document the outcome and required follow-up care.
(D) If moderate sedation or deep sedation/general anesthesia is provided, the health record of a patient also must include documentation of:
(1) patient weight;
(2) type of anesthesia used;
(3) type and dosage of drugs administered, if any;
(4) fluid administered, if any;
(5) a record of vital signs monitoring;
(6) patient level of consciousness during the procedure;
(7) duration of the procedure;
(8) complications related to the procedure or anesthesia, if any; and
(9) time-oriented anesthesia record.
HISTORY: 2014 Act No. 222 (S.1036), § 2, eff January 1, 2015.