(a)The term "dental records" includes, but is not limited to documentation of: identification of 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, 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. [(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)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 (5) 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 if taken; (5)If not recorded, an explanation why vital signs were not obtained. [(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)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 rule 108.7(6) (of this title relating to Minimum Standard of Care, General); (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 licensed dentist, and confirmable identification of person making record entries if different from provider dentist; (12)When any of the items in paragraphs (1) through (11) of this section are not indicated, the record must include an explanation why the item is not recorded. [(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.] (d)[(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. (e)[(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. (f)[(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. (g)[(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 radiograph [x-ray] duplicating service, may be equal to actual cost verified by invoice. (3)Reasonable costs for radiographs duplicated by means other than by a radiograph [an x-ray] duplicating service shall not exceed the following charges: (A)a full mouth radiograph series: $15.00; (B)a panoramic radiograph [x-ray]: $15.00; (C)a lateral cephalometric radiograph [cephalogram ]: $15.00; (D)a single extra-oral radiograph [x-ray]: $5.00; (E)a single intra-oral radiograph [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.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State, on July 9, 2001
TRD-200103901 Jeffry R. Hill
Executive Director
State Board of Dental Examiners
Earliest possible date of adoption: August 19, 2001
For further information, please call: (512) 463-6400
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