(a) 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. Adequate records are records
from which diagnoses can be made and which clearly and accurately document
all of the facts related to the treatment of a dental patient, including diagnoses,
services, treatments and progress of care. Records shall be kept for a period
of not less than five (5) years.
(b) The term "dental records" includes, but is not limited
to documentation of: identification of practitioner providing treatment; medical
and dental history; limited physical examination; x-rays and radiographs;
dental and periodontal charting; diagnoses made; treatment plans; informed
consent statements or confirmations; study models, casts, molds, impressions;
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.
(c) The dispensing, administering, or prescribing of narcotic
drugs, dangerous drugs, or controlled substances 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. All such drugs and substances which are
kept in the dental office or under the control of the dentist are to be maintained
by a centralized inventory which shall indicate dates acquired, description
and quantity of drugs, date, method, quantity dispensed, and the patient to
whom the drug is dispensed.
(d) All records pertaining to Controlled Substances and Dangerous
Drugs shall be maintained in accordance with the Texas Controlled Substances
Act.
(e) Dental records are the sole property of the dentist who
performs the dental service. Such records shall be available for inspection
by the patient after and upon appointment with a dentist. This shall not prohibit
the transfer of a copy of records to the patient, or to an agreed designated
consultant for ascertainment of facts, nor transfer of original records to
another Texas dental licensee who will provide treatment to the patient. The
transferring dentist shall retain a copy of the written record if such original
transfer is made.
(f) A dentist who leaves a location or practice, whether by
retirement, sale, transfer, termination of employment or otherwise, shall
either 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, and the State Board of Dental Examiners shall
be notified within fifteen (15) days of any such event, giving full information
concerning the dentists and location(s) involved. A maintenance of records
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; and that the
dentist(s) performing the service(s) recorded shall have access to and control
of the records for purposes of inspection and copying. A transfer of records
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.
(g) 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.
(h) A dentist shall furnish copies of dental records to a patient
who requests his or her dental records. Requested copies including radiographs
shall be furnished within thirty (30) days of the date of the request, provided
however, that copies need not be released until payment of copying costs has
been made. Records may not be withheld based on a past due account for dental
care or treatment previously rendered to the patient.
(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 x-ray duplicating
service, may be equal to actual cost verified by invoice.
(3) Reasonable costs for radiographs duplicated by means other
than by an x-ray duplicating service shall not exceed the following charges:
(A) a full mouth series: $15.00;
(B) a panoramic x-ray: $15.00;
(C) a lateral cephalogram: $15.00;
(D) a single extra-oral x-ray: $5.00;
(E) a single intra-oral x-ray: $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.
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