Regulation .03 Clinical Charts.
Regulation .03 Clinical Charts.LinkCopy Citation
A.
Each patient’s clinical chart shall include at a minimum the following:
(1)
Patient's name and date of treatment;
(2)
Reasons for the patient’s visit;
(3)
Treatment plans that are signed and dated by both the treating dentist and the patient;
(4)
Patient’s complaints;
(5)
Diagnosis and treatment notes;
(6)
Progress notes;
(7)
Post operative instructions;
(8)
Study models;
(9)
In-person conversations, telephone conversations, and other correspondence with the patient or their representative;
(10)
Identification of medications prescribed, administered, dispensed, quantity, and directions for use;
(11)
Clinical details with regard to the administration of:
(a)
Nitrous oxide;
(b)
Anxiolytics;
(c)
Sedation; and
(d)
General anesthesia.
(12)
Radiographs of diagnostic quality;
(13)
Periodontal charting;
(14)
Laboratory work authorization forms and correspondence to and from laboratories;
(15)
Informed consent;
(16)
Copies of correspondence and reports provided to other health care providers, diagnostic facilities, and legal representatives;
(17)
Records and reports provided by other health care providers and diagnostic facilities;
(18)
Details regarding referrals and consultations;
(19)
Patient complaints pertaining to the dentist and staff, and their manner of resolution;
(20)
Noncompliance and missed appointment notes; and
(21)
Dismissal letter.
B.
A dentist who performs diabetes or blood pressure screening shall include the results of the screenings in the patient’s clinical chart.