subchapter 16t - PATIENT RECORDS

 

SECTION .0100 – PATIENT RECORDS

 

21 NCAC 16T .0101          RECORD CONTENT

A dentist shall maintain complete treatment records on all

patients for a period of at least 10 years.  Treatment records may include such

information as the dentist deems appropriate but shall include:

(a)           Patient's full name, address and treatment

dates;

(b)           Patient's nearest relative or responsible

party;

(c)           Current health history;

(d)           Diagnosis of condition;

(e)           Specific treatment rendered and by whom;

(f)            Name and strength of any medications

prescribed, dispensed or administered along with the quantity and date.

provided;

(g)           Work orders issued during the past two

years;

(h)           Treatment plans for patients of record,

except that treatment plans are not required for patients seen only on an

emergency basis;

(i)            Diagnostic radiographs, study models and

other diagnostic aids, if taken; and

(j)            Patients' financial records and copies of

all insurance claim forms.

 

History Note:        Authority G.S. 90-28; 90-48;

Eff. October 1, 1996;

Amended Eff. July 1, 2015.

21 NCAC 16T .0102          TRANSFER OF

RECORDS UPON REQUEST

A dentist shall, upon request by the patient of record,

provide all information required by the Health Insurance Portability and

Accountability Act (HIPAA) and this Rule, including original or diagnostic

copies of radiographs and a legible copy of all treatment records to the

patient or to a licensed dentist identified by the patient.  The dentist may

charge a fee not exceeding the actual cost of duplicating the records.  The

records shall be provided within 30 days of the request and production shall

not be contingent upon current, past or future dental treatment or payment of

services.

 

History Note:        Authority G.S. 90-28; 90-48;

Eff. October 1, 1996;

Amended Eff. July 1, 2015; April 1, 2014; November 1,

2008.