# COMAR Title 10 — Maryland Department of Health

## Subtitle 44 — Board of Dental Examiners

### Chapter 30 — Record Keeping

#### Regulation .03 Clinical Charts.

*COMAR 10.44.30.03*

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.