| (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 dental records 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 from the last date of treatment by the
dentist. If a patient was younger than 18 years of age when last treated
by the dentist, the records shall be maintained by the dentist until
the patient reaches age 21 or for five years from the date of last
treatment, whichever is longer. Dentists shall retain records for
a longer period of time when mandated by other federal or state statute
or regulation. 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 physical
evaluation;
(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(7) 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. A dentist who assumes ownership of
the records pursuant to this paragraph shall maintain the records
in a manner consistent with this section and is responsible for complying
with subsections (f) and (g) of this section.
(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.
|
| Source Note: The provisions of this §108.8 adopted to be effective February 20, 2001, 26 TexReg 1494; amended to be effective December 30, 2001, 26 TexReg 10570; amended to be effective February 2, 2010, 35 TexReg 634; amended to be effective September 14, 2010, 35 TexReg 8344; amended to be effective June 10, 2012, 37 TexReg 4043; amended to be effective May 29, 2013, 38 TexReg 3346; amended to be effective June 11, 2014, 39 TexReg 4428; amended to be effective September 3, 2014, 39 TexReg 6855 |
