18 Va. Admin. Code § 60-21-90

Current through Register Vol. 41, No. 4, October 8, 2024

Section 18VAC60-21-90 - [Effective 10/24/2024] Patient information and records

A. A dentist shall maintain complete, legible, and accurate patient records for not less than six years from the last date of service for purposes of review by the board with the following exceptions:

1. Records of a minor child shall be maintained until the child reaches 18 years of age or becomes emancipated, with a minimum time for record retention of six years from the last patient encounter regardless of the age of the child;

2. Records that have previously been transferred to another practitioner or health care provider or provided to the patient or the patient's personal representative pursuant to § 54.1-2405 of the Code of Virginia; and

3. Records that are required by contractual obligation or federal law may need to be maintained for a longer period of time.

B. Every patient record shall include documentary evidence of the following:

1. Patient's name on each page in the patient record;

2. A health history taken at the initial appointment that is updated (i) when analgesia, sedation, or anesthesia is to be administered; (ii) when medically indicated; and (iii) at least annually;

3. Diagnosis and options discussed, including the risks and benefits of treatment or nontreatment and the estimated cost of treatment options;

4. Consent for treatment obtained and treatment rendered;

5. List of drugs prescribed, administered, or dispensed and the route of administration, quantity, dose, and strength;

6. Radiographs, digital images, and photographs clearly labeled with patient name, date taken, and teeth identified;

7. Notation of each treatment rendered, the date of treatment and of the dentist, dental hygienist, and dental assistant II providing service;

8. Duplicate laboratory work orders that meet the requirements of § 54.1-2719 of the Code of Virginia, including the address and signature of the dentist;

9. Itemized patient financial records as required by § 54.1-2404 of the Code of Virginia;

10. A notation or documentation of an order required for treatment of a patient by a dental hygienist practicing under general supervision as required in 18VAC60-21-140 B; and

11. The information required for the administration of moderate sedation, deep sedation, and general anesthesia required in 18VAC60-21-260 D.

C. Records shall not be withheld because the patient has an outstanding financial obligation.

D. A reasonable cost-based fee may be charged for copying patient records to include the cost of supplies and labor for copying documents, duplication of radiographs and images, and postage if mailing is requested as authorized by § 32.1-127.1:03 of the Code of Virginia. The charges specified in § 8.01-413 of the Code of Virginia are permitted when records are subpoenaed as evidence for purposes of civil litigation.

E. Records shall not be abandoned or otherwise left in the care of someone who is not licensed by the board except that, upon the death of a licensee, a trustee or executor of the estate may safeguard the records until they are transferred to a licensed dentist, sent to the patients of record, or destroyed.

F. Patient confidentiality must be preserved when records are destroyed.

18 Va. Admin. Code § 60-21-90

Derived From, Virginia Register Volume 32, Issue 05, eff. 12/2/2015; Amended, Virginia Register Volume 35, Issue 05, eff. 11/28/2018; Amended, Virginia Register Volume 41, Issue 2, eff. 10/24/2024.

Statutory Authority: § 54.1-2400 of the Code of Virginia.