Section 33.209. Preparing, maintaining and retaining patient records

(a) A dentist shall maintain a dental record for each patient which accurately, legibly and completely reflects the evaluation and treatment of the patient. A patient dental record shall be prepared and maintained regardless of whether treatment is actually rendered or whether a fee is charged. The record shall include, at a minimum, the following:

(1) The name and address of the patient and, if the patient is a minor, the name of the patient’s parents or legal guardian.

(2) The date of each patient visit.

(3) A description of the patient’s complaint, symptoms and diagnosis.

(4) A description of the treatment or service rendered at each visit and the identity of the person rendering it.

(5) Information as required in § 33.208 (relating to prescribing, administering and dispensing medications) and this section with regard to controlled substances or other medications prescribed, administered or dispensed.

(6) The date and type of radiographs taken and orthodontic models made, as well as the radiographs and models themselves. Notwithstanding this requirement, the dentist may release orthodontic models to the patient. This transaction shall be memorialized on a form which is signed by the patient. The signed form shall become part of the patient’s record.

(7) Information with regard to the administration of local anesthesia, nitrous oxide/oxygen analgesia, conscious sedation, deep sedation or general anesthesia. This shall include results of the preanesthesia physical evaluation, medical history and anesthesia procedures utilized.

(8) The date of each entry into the record and the identity of the person providing the service if not the dentist of record-for example, dental hygienist, expanded function dental assistant, dental assistant, and the like.

(b) A patient dental record shall be retained by a dentist for a minimum of 5 years from the date of the last dental entry.

(c) Within 30 days of receipt of a written request from a patient or a patient’s parents or legal guardian if the patient is a minor, an exact copy of the patient’s written dental record, along with copies of radiographs and orthodontic models, if requested, shall be furnished to the patient or to the patient’s new dentist. This service shall be provided either gratuitously or for a fee reflecting the cost of reproduction.

(d) The obligation to transfer records under subsection (c) exists irrespective of a patient’s unpaid balance for dental services or for the cost of reproducing the record.

(e) Dentists shall provide for the disposition of patient records in the event of the dentist’s withdrawal from practice, incapacity or death in a manner that will ensure their availability under subsection (c).

(f) The components of a patient dental record that are prepared by a dentist or an agent and retained by a health care facility regulated by the Department of Health or the Department of Public Welfare shall be considered a part of the patient dental record required to be maintained by a dentist, but shall otherwise be exempt from subsections (a)—(e). The components of a patient dental record shall contain information required by applicable Department of Health and Department of Public Welfare regulations—see, for example, 28 Pa. Code § 141.26 (relating to patient dental records)—and health care facility bylaws.

(g) This section does not restrict or limit the applicability of recordkeeping requirements in § § 33.207 and 33.208 (relating to prescribing, administering and dispensing controlled substances; and prescribing, administering and dispensing medications).

(h) A dentist’s failure to comply with this section will be considered unprofessional conduct and will subject the noncomplying dentist to disciplinary action as authorized in section 4.1(a)(8) of the act (63 P. S. § 123.1(a)(8)).

The provisions of this § 33.209 adopted June 23, 1995, effective June 24, 1995, 25 Pa.B. 2492; amended May 12, 2000, effective May 13, 2000, 30 Pa.B. 2359; amended May 13, 2005, effective May 14, 2005, 35 Pa.B. 2880. Immediately preceding text appears at serial pages (266034) to (266036).

Notation

Authority

The provisions of this § 33.209 amended under sections 3(c) and 11.2(a) of the Dental Law (63 P. S. § § 122(o) and 130c(a)).

Notes of Decisions

Patient’s Complaint

The State Board of Dentistry’s findings that the dentist failed to properly record the parents’ complaint was supported by substantial evidence, where, based on the expert testimony, the Board found that the dentist should have recorded the parents’ complaint that their son had black spots on his teeth or recorded ‘‘no complaints’’ on the child’s record, and where the Board stated that while the dentist recorded the child’s cavities, such an activity constituted a diagnosis, which is a separate recording requirement. Watkins v. State Board of Dentistry, 740 A.2d 760 (Pa. Cmwlth. 1999).

Cross References

This section cited in 49 Pa. Code § 33.340 (relating to duties of dentists who are unrestricted permitholders); and 49 Pa. Code § 33.340a (relating to duties of dentists who are restricted permit I holders); and 49 Pa. Code § 33.340b (relating to duties of dentists who are restricted permit II holders).