2013 BCCOHP Dental Recordkeeping Guidelines PDF

Dental Recordkeeping Guidelines Applies to Dentists & Certified Dental Assistants The British Columbia College of Oral Health Professionals (BCCOHP) was created on September 1, 2022 through the amalgamation of four health regulatory colleges: the College of Dental Hygienists of BC, the College of D...

Dental Recordkeeping Guidelines Applies to Dentists & Certified Dental Assistants The British Columbia College of Oral Health Professionals (BCCOHP) was created on September 1, 2022 through the amalgamation of four health regulatory colleges: the College of Dental Hygienists of BC, the College of Dental Surgeons of BC, the College of Dental Technicians of BC, and the College of Denturists of BC. All current requirements for standards of clinical and ethical practice issued by the four colleges remain in place upon amalgamation. This document was created by the College of Dental Surgeons of BC and will be updated to reflect the amalgamation.  Dental Recordkeeping Guidelines April 2013 Practice Guidelines of the College of Dental Surgeons of BC (CDSBC) should be considered by all B.C. dentists and certified dental assistants in the care of their patients. It is the responsibility of all practitioners to maintain accurate patient records as recommended in this document. It is important to note that these Guidelines may be used by CDSBC or other bodies in determining whether professional responsibilities and appropriate standards of practice have been maintained. Contents 2 Introduction 4 Medical and Dental History 5 Confidentiality 6 Dental Examination 8 Informed Consent 9 Treatment Records 10 Electronic Recordkeeping 11 Financial Records  12 Drug Records 13 Ownership, Retention, Transfer and Disposition of Dental Records  Introduction of professional misconduct – the Inquiry and Discipline Committees – may use this document as a reference when considering a particular case. It is important, therefore, that dentists and CDAs carefully read this document and take the necessary action to ensure that their dental recordkeeping complies with the recommendations contained in these Guidelines. Once a practitioner has determined that the dental record form being used allows for the collection and retention of the required patient information, all that is required is that the records be kept and updated each time there is contact with a patient. Professional, ethical and legal responsibilities dictate that a complete chart and record documenting all It is the CDSBC’s opinion that practice aspects of each patient’s dental care must be guidelines should be sufficiently flexible maintained. Good records facilitate the provision of to allow practitioners to exercise their effective clinical care and ensure the continuity and judgment with respect to particular situations. comprehensiveness of oral/dental health services. Accordingly, the terms “appropriate” and Patient records must be accurate, well-organized, “pertinent” have been used throughout these legible, readily accessible and understandable. If the Guidelines to indicate where professional practitioner of record were for any reason to become judgment is expected. unable to practise, another dentist should be able to easily review the chart and carry on with the care of the patient. Purposes of Records These Guidelines are designed to provide assistance A dental record should provide an accurate picture to practitioners and comfort to the public that dental of the patient’s general health, as well as oral/dental patient information is both accurate and confidential. status and any patient concerns and requests. It should include the proposed treatment plan and Risk Management any treatment performed, as well as all supporting In recent years, the requirements for dental records documentation. Outcome of treatment should be management have been redefined, especially as documented and any deviations from expected they relate to documentation, release of information outcomes should be recorded on the patient chart and storage. Dentists are expected to be familiar at the time of service. Patients should be advised with current expectations and to ensure that their of compromised results as soon as the dentist is staff members understand and adhere to the aware of the situation. All relevant information updated protocols. presented to the patient should be documented. Use of this Document Basic Assumptions These Guidelines are designed to help practitioners Patients have a right to expect that their dental meet legal requirements for dental recordkeeping. health information will be kept confidential. They also have application in several areas of Patients have a right (with a few exceptions) responsibility of the CDSBC regarding standards of to review and obtain a copy of their dental practice and quality assurance. The statutory records including consultation reports of other committees of CDSBC that consider allegations practitioners. 2  It is appropriate, where patient consent has been General Recordkeeping Principles obtained, to share dental and medical records In keeping and maintaining acceptable patient with other health professionals as necessary to records, a prudent practitioner would adhere to ensure continuity and quality of care. the following principles: Every dental team member involved in a patient’s All entries should be dated and recorded by hand care should maintain the confidentiality and in permanent ink or typewritten, or be in an security of a patient’s dental records, only sharing acceptable electronic format and be complete, them with other health care professionals for the clear and legible. purpose of assisting in providing optimal care. All entries, including electronic entries, should be Dental records should only be disposed of in a signed, initialled or otherwise attributable to the manner that ensures that the confidentiality of writer and if different, the treating clinician. the information is maintained. Radiographs and other diagnostic aids, such as Essentials of Recordkeeping study models, should be properly labelled, dated and the interpretation of the findings documented The extent of detail required for each record will vary, when considered appropriate by the practitioner. however, certain baseline data should be common to all dental patients. An explanation of the overall treatment plan, treatment alternatives, any risks or limitations of This information includes: treatment and the estimated costs of the treatment accurate general patient information; should be provided to each patient, parent, legal a medical history that is periodically updated; guardian or government-appointed advocate as a dental history; appropriate. This fact should be noted in the patient record. In complex or difficult cases, it is advisable an accurate description of the conditions that are to have such informed consent signed. present on initial examination, including an entry such as “within normal limits” where appropriate; General Patient Information an accurate description of ongoing dental status It is important that patient records contain the at subsequent appointments; following general information for every patient and a record of the significant findings of all supporting that this information be updated at regular intervals. diagnostic aids, tests or referrals such as Information should include the patient’s name, radiographs, study models, reports from specialists; contact information, date of birth, primary care all clinical diagnoses and treatment options; physician, emergency contact name and number, a record that all reasonable treatment planning and insurance information, if applicable. options were discussed with the patient; the proposed and accepted treatment plan; a notation that informed consent was obtained; assurance that patient consent was obtained for the release of any and all patient information to a third party; a description of all treatment that was performed, materials and drugs used and, where appropriate, the prognosis and outcome of the treatment; details about referrals; and an accurate financial record. Dental Recordkeeping Guidelines 3  Medical and Dental History hepatitis A/B/C, jaundice, liver disease or gastrointestinal disorders; kidney disease; immuno-compromising diseases, e.g. HIV positive status, AIDS, leukemias; nutritional status/eating disorders, e.g. anorexia nervosa, bulimia; any prosthetic joints; medications and supplements taken regularly; pregnancy; psychiatric disorders/treatment; drug or alcohol dependency; and Medical History any other conditions or problems of which the A general medical history should be reviewed and clinician should be made aware. initialled by the treating practitioner and dated at the initial examination. The information should be updated Any drug allergies, medical alerts or conditions regularly based on the patient’s age and history and pertinent to the patient’s care should be the update noted in the patient record. conspicuously noted in the patient record. In taking a medical history, dentists must ensure that The dentist should sign and date the medical history. all necessary and relevant medical information is Some practitioners may choose to have the obtained in order to allow for the provision of safe completed history signed by the patient or, in the dental care at the time of treatment and in the future. case of a child, by the parent or legal guardian. It is important that the collection of necessary medical history information be done in a systematic Updating the Medical History manner. In determining, for example, if a patient has Based on their age and history, appropriate had any serious illnesses, conditions or adverse questions for updating the patient’s medical reactions that might impact on the provision of safe information could include: dental care, the following checklist may be helpful: Have there been any changes in your health, details of past hospitalizations and/or serious such as any serious illnesses, hospitalization illnesses, conditions or adverse reactions; or new allergies? If yes, please specify. significant respiratory diseases, e.g. asthma, Are you taking any new medications or has emphysema, tuberculosis; there been any change in your medications? any known allergies; If yes, please specify. peculiar or adverse reactions to any medicines Have you had a new heart problem diagnosed or or injections, e.g. penicillin, Aspirin or local had any change in an existing heart problem? anaesthetics; When was your last medical checkup? heart disease, heart attack, blood pressure Were any problems identified? If yes, problems or stroke; please explain. history of infective endocarditis; For women only: Are you breastfeeding or epilepsy or seizures; pregnant? If pregnant, when is the expected blood disorders, bleeding or bruising tendency; delivery date? endocrine disorders, e.g. diabetes; cancer/radiation treatment/chemotherapy; 4 Dental History Privacy Compliance In addition to clinical findings, the patient record must Dentists need to be aware of the requirements of contain a notation of any significant dental history the Personal Information Protection Act of British including an assessment of caries risk and periodontal Columbia (PIPA) and other laws dealing with privacy. health. Information obtained regarding a patient’s Any discussion of the latter is beyond the scope of dental history can supplement the clinical examination, these Guidelines, which are confined to a brief and assist in the planning and sequencing of dental summary of PIPA. care that is necessary and appropriate to improve the The purpose of PIPA is to govern the collection, patient’s dental health status. use and disclosure of personal information by organizations, including dental offices. All dentists must comply with the requirements of PIPA regarding patient information and dental records, Confidentiality including the disclosure and transfer of patient information and dental records. Under PIPA, a dentist must either assume the role of Privacy Officer or assign this role to an individual within the practice. Privacy Officers are required to: put in place information handling practices; prepare and make available a written public statement about the dental office’s information handling practices; prepare a policy for their office, including a description of the purpose(s) for collecting personal information and how it will be used and disclosed; Patient information and dental records contain ensure that employees and all other agents are sensitive personal information and must be kept in appropriately informed of their obligations under PIPA; confidence. A patient’s personal information and take reasonable steps to ensure personal dental records must be protected from any information in the practice’s custody or control is unauthorized use or disclosure, except as required protected against theft, loss, unauthorized use, by law or where the patient has given their express disclosure, copying, modification, and disposal (this consent, ideally in writing. includes ensuring proper security for any off-site Dentists are also responsible for ensuring that their work with patient information or dental records, or staff is aware of the requirement of maintaining remote access to such information or records); confidentiality with respect to patient information ensure that patient information and dental records and dental records. Dentists and their staff must in the dentist’s custody or control are retained, also be aware of the requirement for patient consent transferred, and disposed of in a secure manner before the disclosure or transfer of any patient and in accordance with PIPA; and information or dental records to any third party, ensure that patient inquiries regarding the handling including to other family members. of their personal information or access requests Confidentiality requirements apply to paper, under PIPA are answered promptly and appropriately. electronic, and other forms of patient information and dental records. The foregoing brief summary is not and cannot be considered to be definitive legal advice, and in Records should be stored securely, not left all cases, dentists should consult with their own unattended or in public areas of the office, and legal counsel. destroyed appropriately and securely at the end of the required retention period (see page 13). Dental Recordkeeping Guidelines 5  Dentists may wish to review the full text of PIPA. Vital Signs – The necessity of this information An unofficial copy is available at www.bclaws.ca depends on the complexity of the dental treatment (ensure that the version of PIPA reviewed is current). required, the medical history and present state of Some further information about compliance with health of the patient, and whether sedation or PIPA is at oipc.bc.ca/resources/guidance- general anaesthesia will be used. documents/. Periodontal Evaluation – This may be carried out Patient consent, preferably in writing and signed by in two stages, namely a recognized periodontal the patient, should be obtained for the disclosure of screening examination for adolescent and adult any patient information or dental records to, or the patients [i.e. Periodontal Screening Record (PSR), obtaining of any patient information or dental records Community Periodontal Index of Treatment Needs from, another dentist, the patient’s physician, or an (CPITN)] and a complete periodontal examination authorized representative. There may be situations for those whose screening results warrant in-depth where verbal consent may be acceptable, provided follow-up. such consent is documented in the patient’s chart; Arch Relationship and Growth/Development appropriate professional judgment about what form Evaluation – Where appropriate. patient consent should take is, of course, required in each case. As part of a complete oral examination, it is important to show in the patient record that each of these areas has been addressed during the examination. For those patients with little or no history of dental disease and a relatively healthy mouth, this can be accomplished with a notation such as “within normal limits” for most Dental Examination of the areas. While the choice of patient record or chart form is left to the individual practitioner, it is important that there is sufficient space to record all relevant information and to update it whenever necessary. These records must reflect initial conditions and differentiate these from subsequent findings. Any part of the record used on an ongoing basis, such as an ondontogram, must allow sufficient space to record all relevant information and The patient record should include chart recordings, updates as necessary. and written and/or electronic descriptions of the Changes in clinical findings noted at subsequent conditions that are present on examination of re-examination or emergency appointments the patient. should be recorded in writing in the patient This information can be categorized as follows: record or noted on a separate odontogram. Extra-Oral Evaluation Soft Tissue Evaluation Dentition Evaluation 6 Radiographs and Dental Records The diagnosis made from a review of the data that was collected and recorded during the clinical Radiographs are an important part of the patient examination, supplemented by necessary record. They should be clearly labelled with the radiographs and/or diagnostic study models and/or patient's and the dentist's name, dated and be of the results of any tests or consultations, should be acceptable diagnostic quality. All radiographs taken in noted in the patient record. Where possible, all a dental office should be noted, including any retakes diagnoses should be stated specifically. It should also or problems encountered. be recorded that this information was communicated The following factors may influence the diagnostic to the patient. quality of radiographs: The treatment plan should list the recommended film fog services to be performed for the patient and should stain, discolouration or foreign marks be based on the medical and dental history, clinical inadequate image density examination and diagnoses. elongated or foreshortened images The treatment plan should be supported by a complete and accurate clinical record and take into overlapping of interproximal surfaces account the relative urgency and severity of the inadequate view of the apex or apices patient’s condition. Some indication should also be The number and type of radiographs prescribed for provided as to: new patients should be appropriate to the age, oral the urgency and order of treatment; health status and dental history of the patient. the options presented to the patient for materials The decision to take recall radiographs should be and methods; based on the patient’s age, general or systemic treatment options and alternatives, including condition, dental history, current status and any no treatment; existing radiographs. Recall and/or post-operative all recommendations, instructions and advice radiographs should only be taken when judged given, together with pertinent patient comments; necessary, not on a routine basis. discussions about financial implications and Whenever a patient, patient’s guardian or authorized arrangements for payment options discussed; representative refuses recommended radiographs, an indication of the decision of the patient with such refusal should be noted in the patient record. respect to choice of treatment and that informed consent has been obtained; and Diagnosis and Treatment Planning a planned schedule of reassessment and/or The patient record should contain statements that outcome assessments on extended or complex identify any immediate needs or chief complaints as treatment plans. presented by the patient. Other than for emergency or single appointment situations, the overall condition For extended or complex treatment, the treatment of the teeth and supporting structures should also be plan should also include a schedule of visits, reviewed and documented regularly. estimated timeline and, where appropriate, provide a brief description of the services to be performed It is recommended that a statement regarding caries at each appointment. Any conditions that are being risk and the periodontal status of the patient based on monitored should be noted, as well as the fact that the history and examination be included in the record. the patient was informed accordingly. The extent Any discussions regarding general recommendations to which the patient has accepted or rejected the about future treatment options, a maintenance recommended treatment should also be recorded, schedule, and the cost of treatment should be where applicable. recorded in the patient record. Dental Recordkeeping Guidelines 7  Informed Consent Guidelines for Obtaining Consent The standard for obtaining informed consent used to be what a reasonable prudent practitioner would disclose. In the early 1980s, the standard changed to a more patient-centered view. Now, the standard is what a reasonable person, in the patient’s position, would need to know to make a decision. This makes it imperative that dentists know their patients and tailor the information that is provided to the needs of each patient. In order for consent to be informed, the dentist must provide the patient with certain information: Informed consent is based on the right of each the diagnosis or problem noted, the treatment person to determine what will be done to his or alternatives available (not just the ones that the her own body. Informed consent guarantees each dentist provides), the risks and benefits of each person the right to refuse treatment, to consent treatment, the estimated cost of each option, the to treatment, and to withdraw consent to treatment. nature and purpose of the proposed treatment, and Informed consent also ensures that the person the likely consequences of not having treatment. understands the risks and benefits of each treatment The dentist should be certain that the patient option presented as well as the costs involved. understands what has been explained and has Consent may be either implied or express. Implied consented to the procedure(s). consent is usually ascertained by the actions of the Although both oral and written consent are legally patient, as with the patient who opens his or her acceptable, oral consent should be confirmed in mouth for an examination. Express consent may writing where risks are significant. be oral or written. Regardless of whether the patient consents in Informed consent is not an event or specific form writing or orally, the dentist should keep a record but rather an ongoing dialogue with patients that of the nature of the conversation, the information begins at the first visit to the office and continues provided and the patient’s decision. as treatment progresses. Implied consent may be sufficient if: Other Significant Consent Information the patient voluntarily comes to the dentist’s office There is no age of consent in B.C. If the dentist is and the dentist is performing a simple examination of the opinion that a patient is capable of providing or non-invasive procedure that poses no risk of his or her own consent to treatment, then the harm to the patient. dentist can rely on that consent. Consent for Express consent should be obtained when: payment of the treatment may be a separate issue. any treatment is required that poses a potential A legal guardian or other substitute caregiver must risk to the patient, even if the likelihood for consent to dental procedures for incompetent potential complications is low. This includes any patients or children who are not capable of procedure from something such as a simple understanding information that is relevant to filling to more complex procedures such as oral making a decision about the treatment and not surgery, extraction or prosthetic rehabilitation. able to appreciate the reasonable foreseeable consequences of a decision or lack of a decision. 8  Consent is not required in emergency situations complete and comprehensive description of the defined under the B.C. Health Care (Consent) and patient’s ongoing care. They should also indicate Care Facility (Admission) Act, where a health care the reason for the particular treatment, if it is not provider may provide health care to an adult apparent from the record (i.e. loose or fractured without the adult’s consent if: restoration) and the tooth/teeth or area of the mouth (a) it is necessary to provide the health care being treated. It is also advisable to note on the without delay in order to preserve the adult’s patient record whenever a discussion of possible life, to prevent serious physical or mental limitations of treatment was held with the patient. harm or to alleviate severe pain; The progress notes for each visit should provide (b) the adult is apparently impaired by drugs or a concise and complete description of all services alcohol or is unconscious or semi-conscious rendered (including any consultation provided by for any reason or is, in the health care telephone) and include: provider’s opinion, otherwise incapable of the date of treatment; giving or refusing consent; the treating clinician’s identity; (c) the adult does not have a substitute decision the area or tooth number being treated and the maker, guardian or representative who is identity of the writer; authorized to consent to the health care, is diagnostic tests; capable of doing so and is available; and the type and quantity of local anaesthetic used; (d) where practicable, a second health care provider confirms the first health care the materials used; provider’s opinion about the need for the any other drugs that are prescribed, dispensed or health care and the incapability. administered and the quantity and dose of each; and all recommendations, instructions, explanations and advice given to the patient and any discussion with the patient regarding possible complications, Treatment Records outcomes, prognoses and follow-up requirements. Dentists may rely on office staff to document their chart entries, but the dentist is expected to sign or initial each entry after reviewing it for accuracy and completeness to ensure that it captures the necessary information. Entries made by dictation must be initialled by both the dentist and the writer. Any complication and/or adverse outcome should be well documented. The chart entry should specifically note the patient was advised about the incident and the available options to address it. As care is provided to the patient, circumstances may change and require alterations to the initial and/ Clinical Progress Notes or recommended treatment plan. Such alterations Progress notes describe the treatment rendered should be clearly documented, along with a notation for the patient at each appointment. They should that they were discussed with and agreed to or be well-organized, legible (handwritten, typewritten declined by the patient. or an acceptable electronic format), and provide a Dental Recordkeeping Guidelines 9  Helpful Tips for Chart Entries Electronic Recordkeeping When composing chart entries, adopt a methodical style. For example, the individual steps for each service may be documented in the order they were performed. Abbreviations and short forms are commonly employed for brevity. This is an acceptable practice, but they should be easily decipherable and used in a consistent fashion. Referral Documentation Notations of referral to a specialist, as well as copies of any reports/correspondence to and from specialists The use of electronic recordkeeping by dentists, should be kept on file. A written or electronic including digital radiography, has grown substantially summary of any verbal conversations about a patient in B.C., and the sophistication of hardware and with another dentist, specialist or other health care software continues to evolve. In addition, the public professional should also be noted in the chart. has a heightened sense of awareness and increased expectations around the issues of confidentiality The use of procedures or work outsourced to a dental and accuracy. laboratory should be noted, detailing the dates of service and make-up of materials used, e.g. gold It is important to note that electronic records content, and the name of the lab used, if appropriate. must comply with all requirements of traditional paper records as outlined in other areas of these A patient’s consent must be obtained before his Guidelines. or her dental conditions and/or treatment needs are discussed with any third party. Electronic Recordkeeping System It is also important to record patient refusal of a referral recommendation. Requirements Dentists may make and keep electronic records Patient Follow-up and Recall provided certain guidelines are adhered to. Practitioners must also take steps to ensure the Examinations reliability of data input and the subsequent It is advisable to have a systematic notification accessibility and security of information. procedure for the ongoing care of patients, especially When it comes to accuracy, the most important as it relates to the completion of treatment, feature of electronic recordkeeping is an audit trail so postoperative checks, treatment follow-up and the authenticity of the records can be verified by any outcomes. The recommended return date, if applicable, party who has an interest or requirement to do so. The should be noted on the chart. It is also advisable to audit trail should follow any changes that have ever keep a record of missed appointments or cancellations. been made to the records to ensure that those When patients are seen for follow-up or changes have not compromised the integrity of reassessment, the chart entries should include: the record. the type of examination conducted (recall, It is important that any electronic recordkeeping emergency, specific area); system employed in a dental practice: a notation that the medical history was reviewed has a login and password to access the data, and/or updated; or otherwise provide reasonable protection the findings of the examination; and against unauthorized access, and can authenticate the details of any further treatment recommended all entries; and rendered. 10  provides an accurate visual display of the recorded Financial Records information and is capable of retrieving and printing this information within a reasonable time period; has an audit trail that: –– records the author, time, date, workstation (for networked systems) of each entry for each patient with respect to the clinical or financial data entry, and is capable of being printed separately from the recorded information for each patient; –– preserves the original content of the recorded information (text, image or chart) in a read- only format that when changed or updated Another important facet of the patient record relates tracks the author, time, date, and workstation to financial matters. It is prudent to include in the (for networked systems) of the modification; patient record a note or notes about the financial provides a means of visually displaying the clinical arrangements and agreements made with the patient and financial records of each patient by patient and/or guardian concerning the settlement of accounts. name and is easily printed or transferred with the The financial record for each patient must include: inclusion of all of the original and modified entries, and the dates, order of entry and authors; a copy of any written agreement with a patient; has the capability to provide good quality printed the date and amount of all fees charged; copies of the records and digitized images; the date and amount of all payments made; stores the original data in a read-only format an itemized listing of all commercial laboratory from within the dental program itself, but protects fees that were incurred in respect to prosthetic, the data files from entry and alteration from restorative or orthodontic services; and the database; copies of all dental claim forms for the preceding backs up files on a removable medium that allows two years. data recovery, or provides by other means, If dental treatment is provided for a patient on a basis reasonable protection against loss, damage, and/ other than fee-for-service, or where the responsibility or inaccessibility of patient information; and for payment is with a person other than the patient or ensures the privacy of the patient’s personal patient’s guardian, practitioners should be aware of information is properly safeguarded in both the the following recordkeeping requirements. Any such electronic recordkeeping and in the transfer of agreement with a patient must: the patient’s records. be in writing; The dentist and/or staff members need to be be maintained as part of the patient record; properly trained and have technical competence identify the person or persons entitled to with the computer program. dental services under it; Note that diagnostic or study models are considered outline the dental services to which they part of the patient record and must be retained in are entitled; their original analog or digital form; photographs are state the period of time it will be in force; and not acceptable. Dental Recordkeeping Guidelines 11  specify the obligations of the parties in the event Dentists must take adequate steps to protect the practitioner is unable to provide covered services, narcotics and controlled drugs in their possession including the obligations to make further payments from loss or theft. It is recommended that and the application of payments that were narcotics and controlled drugs be kept in a locked previously made. cupboard out of sight and reach of patients or prospective patients. Business Records Dentists must store benzodiazepines and targeted If payments for dental services are made on behalf of a substances in a place used for the purpose of patient by a third party, the financial record must include conducting their professional practice and in an area the patient's authorization if applicable, and the identity in that place where only authorized employees have and authorization of the person or agency making such access. A drug register must record and account for payment (XYZ Insurance Company, WorkSafeBC, ICBC, all narcotics, controlled drugs, benzodiazepines and Ministry of Housing and Social Development). targeted substances that are kept on site. The register should also be kept in a secure area in the Dentists must also keep business records for the office, preferably with the drugs. practice, including fees charged and received, scheduling (including day sheets), laboratory services Whenever drugs in the above-mentioned classes and clinical equipment maintenance. Business records are used or dispensed, a record containing the chronicle the day-to-day activities in a practice and name of the drug, number dispensed, name of the although the significance of some of this information patient and date should be entered in the register. may seem to diminish after the fact, it can become Each entry should be initialled or attributable to very important in the event of a complaint or a lawsuit. the person who made the entry. In addition, this Practitioners should be aware of provincial and federal same information should be recorded in the legislation governing business records such as the patient record along with any instructions given. Income Tax Act. Prescription pads should never be pre-signed. They should be kept out of reach of patients, prospective patients or visitors to the office. Drug Records Duplicate prescription pads should be kept in a secure place that is accessible only by the dentist. Drugs may only be provided or dispensed to dental patients of record, for dental conditions being treated, and according to accepted dispensing protocols. It is not acceptable for dentists or their staff to access in-office supplies of narcotics, controlled drugs or other drugs that normally require a prescription, for their own personal use or use by their family members. The following information or a copy of the prescription must be included in the patient record: date and method name, strength, quantity and form of drug directions for use of drug (except administration) condition being treated and/or dental treatment provided 12  In addition to clinical records, other records that must Ownership, Retention, be retained include appointment records, lab Transfer and Disposition prescriptions and invoices. Diagnostic or study models of Dental Records are also considered part of the permanent patient record and must be kept for the prescribed period. Working models do not have to be retained for any specific period of time. A decision to keep working models should be based on the complexity of the case and is left to the judgment of the individual practitioner. Exceptions The above guidelines do not apply to minors and persons under a disability. In these cases, the limitation periods do not begin running until the person turns 19 or until the disability ends. Minors Ownership of Records Records relating to minors must be retained for 16 years after the day the minor reaches the age of 19. Under common law, and in the absence of an agreement to the contrary, the owner of a dental Persons Under Disability practice owns all patient charts. A dentist leaving The Limitation Act defines a “person under a or selling a practice should ideally give patients disability” as someone who is incapable of or advance written notice about the change. If the substantially impeded in managing their affairs. outgoing dentist is unable to do so, it becomes the Records relating to persons under disability must be responsibility of the incoming dentist to notify patients kept for 16 years that he or she is in possession of their records. after receiving formal notice that the person’s disability has ended. Retention of Records In many cases, formal notice will not be provided The Limitation Act sets the time limits people have to and it will be difficult or impossible to know if or sue one another in civil court. This has implications for when the disability has ended. In those cases, the length of time dentists must retain patient records. records must be kept indefinitely. A new Limitation Act was introduced in British This information is provided only as a general guide, Columbia, effective June 1, 2013. and should not be taken as legal advice. There are General Guidelines additional exceptions in cases involving fraud, Dentists must now maintain complete patient records concealment, acknowledgement, and where a as follows: notice to proceed has been delivered. Dentists who have specific questions about the Limitation Act Records for which the most recent entry was should review the legislation and consult a lawyer. created on or after June 1, 2013 must be kept for 16 years from the date of last entry. Records for which the most recent entry was created before June 1, 2013, must be kept for 31 years (the ULP under the former Limitation Act, plus one year for service) from the date of last entry or until June 1, 2029 (whichever comes first). Dental Recordkeeping Guidelines 13  Release and Transfer of Records The new Limitation Act deals with records for which the most recent entry was made on or Patients have the right by law to access a copy of after June 1, 2013. Transition rules apply to their complete dental record and dentists are obligated records for which the most recent entry was by law to provide copies of what the patient has made before that date. requested, including radiographs, study models, photographs and other items. If the patient moves For most claims involving dental treatment, a to a different dental practice, records should be person generally has two years from the time transferred within one to two weeks to the new they ought reasonably to have discovered the practitioner. If the new dentist requests records harm to file a lawsuit. This is known as the electronically, they may be provided in that format. basic limitation period (BLP). In most cases, the originating dentist should maintain Since some harm isn’t discovered immediately, all original records on file. The dentist may charge the Limitation Act also has an ultimate reasonable fees for expenses associated with limitation period (ULP). The new Act has copying records, as long as the patient is advised of reduced the ULP from 30 to 15 years. This these charges in advance. means that, subject to some exceptions, a lawsuit can’t be filed more than 15 years after Fee disputes or other disagreements between the the harm was caused, regardless of when it patient and dentist are not grounds to withhold was discovered. access to, or transfer of, patient records. Once harm is discovered, a claimant has two years (the BLP) to file a lawsuit, provided that Disposition of Records not more than 15 years (the ULP) has passed At the end of the retention period, records must since the harm was actually caused. be disposed of in a manner that protects patient confidentiality and maintains physical security of In summary, a lawsuit can potentially be filed the information. Methods include: as long as 15 years after a dentist has completed treatment. Once filed, a claimant confidential return to the individual or dealing has an additional year to serve the lawsuit, so a with the records in accordance with the patient’s dentist may not have notice of the lawsuit for instructions; up to 16 years. controlled physical destruction such as shredding or incineration; and confidential transfer to another agency that will provide appropriate services to destroy the information. The process used to destroy electronic records must render them unreadable and eliminate the possible reconstruction of the records in whole or in part. For more information and resources about dental recordkeeping, including sample charts and patient questionnaires, visit www.cdsbc.org. 14 Notes Dental Recordkeeping Guidelines 15  500 – 1765 West 8th Avenue Phone 604 736-3621 Vancouver, BC Canada V6J 5C6 Toll Free 1 800 663-9169 www.cdsbc.org Fax 604 734-9448 Regulating dentists and certified dental assistants in the public interest Board Approved: December 2009 Updated: April 2013 Originating Committee: Quality Assurance This document has been reprinted with permission based on the Dental Recordkeeping Guidelines published by the Royal College of Dental Surgeons of Ontario. Some modifications have been made to the original text to reflect requirements in British Columbia.