<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".03" citation="COMAR 10.44.30.03" title_num="10" subtitle_num="44" chapter_num="30" heading="Clinical Charts.">
  <paragraph num="A.">
    <text>Each patient’s clinical chart shall include at a minimum the following:</text>
    <paragraph num="(1)">
      <text>Patient's name and date of treatment;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Reasons for the patient’s visit;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Treatment plans that are signed and dated by both the treating dentist and the patient;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Patient’s complaints;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Diagnosis and treatment notes;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Progress notes;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Post operative instructions;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Study models;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>In-person conversations, telephone conversations, and other correspondence with the patient or their representative;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Identification of medications prescribed, administered, dispensed, quantity, and directions for use;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>Clinical details with regard to the administration of:</text>
      <paragraph num="(a)">
        <text>Nitrous oxide;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Anxiolytics;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Sedation; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>General anesthesia.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(12)">
      <text>Radiographs of diagnostic quality;</text>
    </paragraph>
    <paragraph num="(13)">
      <text>Periodontal charting;</text>
    </paragraph>
    <paragraph num="(14)">
      <text>Laboratory work authorization forms and correspondence to and from laboratories;</text>
    </paragraph>
    <paragraph num="(15)">
      <text>Informed consent;</text>
    </paragraph>
    <paragraph num="(16)">
      <text>Copies of correspondence and reports provided to other health care providers, diagnostic facilities, and legal representatives;</text>
    </paragraph>
    <paragraph num="(17)">
      <text>Records and reports provided by other health care providers and diagnostic facilities;</text>
    </paragraph>
    <paragraph num="(18)">
      <text>Details regarding referrals and consultations;</text>
    </paragraph>
    <paragraph num="(19)">
      <text>Patient complaints pertaining to the dentist and staff, and their manner of resolution;</text>
    </paragraph>
    <paragraph num="(20)">
      <text>Noncompliance and missed appointment notes; and</text>
    </paragraph>
    <paragraph num="(21)">
      <text>Dismissal letter.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>A dentist who performs diabetes or blood pressure screening shall include the results of the screenings in the patient’s clinical chart.</text>
  </paragraph>
</regulation>