(a) The term dental records includes, but is not limited to:
identification of the practitioner providing treatment; medical and dental
history; limited physical 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
(relating to Minimum Standard of Care, General).
(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 guidelines set forth on "Dental Radiographic Examinations" published
by the United States Department of Health and Human Services, October 1987,
as amended or reprinted from time to time.
(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);
(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. 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.
(e) 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 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.
(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.
(g) 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 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 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.
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