Quality Resource Guide

Dental Record Keeping 3rd Edition

www.metdental.com

Treatment Plans

Best practices for record keeping include a section

for treatment plans. They should be supported by

documentation of pathology and conditions. The

treatment plan and/or the progress note should

denote alternative treatments discussed with

the patient. Treatment plans should also include

referrals, observations, and re-assessments.

Treatment plan documentation should state that

variation may occur as treatment is delivered.

Ideally, the number and length of appointments

and an estimate of fees should be part of the

treatment plan and its presentation to the patient.

The treatment plan should be dated and signed by

the patient and the provider. Tracking completion

of the treatment line items aids improved patient

management. This process is facilitated by

electronic records.

Maintenance of Dental Record

A dental record must be highly protected; it is

considered a “vital” record because it cannot

be replaced. Original records should never be

released unless subpoenaed or required by

federal of state law. Patients must authorize

the release of their record. The authorization

should be part of the dental record.

Dental

records must be protected in accordance with

federal and state privacy rules. If a practice

transmits health information in an electronic form,

it must also follow Health Insurance Portability

and Accountability Act (HIPAA) rules. Released

in 1996, HIPAA established national standards

for the protection of certain health information

referred to as protected health information (PHI).

The HIPAA Administrative Simplification Interim

Rule released in 2009, established a national

set of security standards for protecting certain

health information that is held or transferred in

electronic form (E-PHI). An updated or “Final Rule”

went into effect March 26, 2013 to strengthen

the privacy and security protections for PHI and

tighten HIPAA enforcement provisions. Dental

records must be stored in a manner that is secure,

yet easily accessible to those authorized to view

them. There is no “one size fits all” plan to ensure

compliance with HIPAA. Individual offices need to

determine the most reasonable and appropriate

protocols to ensure the confidentiality of protected

health information (PHI and e-PHI). Administrative

requirements pertaining to HIPAA are summarized

Table 3

The U.S. Department of Health and Human

Services (HHS) Office for Civil Rights (OCR)

is responsible for enforcing compliance of the

HIPAA Privacy Rule. There are several categories

of HIPAA noncompliance that reflect increasing

levels of culpability. The penalty minimums and

maximums are summarized in

Table 4

. Cases

of willful negligence may be prosecuted by the

Department of Justice, resulting in potential

monetary fine and/or imprisonment.

There are common sense elements to HIPAA as

it relates to patient records:

•

keep files out of view other patients

•

use minimum necessary information when

disclosing information

•

implement both physical and information

technology security

The American Dental Association Nine Step

HIPAA

checklist is a quick reference for

dental

practices.

Due to the increased public awareness concerning

identify theft, many patients are reluctant to

release their Social Security Number (SSN). A

unique patient ID, in lieu of the SSN, should

identify each patient’s physical or electronic

record. State laws and provider contracts define

the regulations controlling ownership and retention

of dental records. In multi-practitioner practices,

responsibility pertaining to the maintenance and

ownership of dental records should be spelled

out in a legal agreement or contract. Each office

should have a clear policy addressing how and

when dental records can be disposed. Typically,

after 2 years of inactivity, a dental record may

be considered inactive. HIPAA generally requires

that inactive records be maintained for 6 years,

or 2 years after a patient’s death. However, some

risk managers recommend records be maintained

indefinitely. The practitioner should know the

specific rules in their own state as they do vary,

or consult an attorney. If the practitioner chooses

to maintain dental charts (either physical or

electronic) beyond the aforementioned timelines,

he or she should consult an attorney to determine

if there are medico-legal concerns, such statute of

limitations, to consider. Charts maintained beyond

the timelines, must be as securely maintained as

active records. An attorney should be contacted

when a dental office permanently closes to ensure

that patients have continued access to their health

information.

The disposal of physical records must be

accomplished in a manner that ensures the

protection of the patient’s privacy. The most

commonly employed method of record disposal is

shredding, which may be accomplished in-office

or out-sourced to a professional shredding

service. Recycling of intact records or record

contents is discouraged, as confidentiality may

be compromised. Physical radiographs should be

removed, de-identified and submitted for silver

recovery or disposal by a certified waste hauler.

An important aspect for managing protected health

information in the era of electronic records is the

data protection. ePHI should be protected both

at rest (while being stored) and in transit. Today

this done through appropriate and up-to-date

firewalling and encryption.

Summary

The dental record (or chart) is the official document

that houses all demographic and diagnostic

information, clinical notes, treatment performed,

implanted material and devices utilized, and

patient-related communications, including patient

recommendations and consents to treatment. This

Quality Resource Guide briefly reviews the basic

elements of documenting and managing a dental

record. Practitioners are encouraged to access

other topic-specific Quality Resource Guides and

the references provided at the end of this Guide for

further guidance.