Patient Records, Confidentiality, and Health Information Privacy
What you must know
The dental record is a clinical and legal document: chart notes, consent forms, radiographs and images, lab prescriptions and reports, medication history, referrals, and correspondence. Entries should be contemporaneous, dated, signed or authenticated electronically, legible, and objective. Corrections are made with a single line, initial and date, plus the correction - never by obliteration, back-dating, or rewriting history after a complaint or lawsuit.
Retention in California is a minimum of seven years from the date of last treatment; practices retain minors' records longer, conventionally until the patient reaches the age of majority plus seven years. Records connected to a pending complaint, investigation, or litigation must be preserved regardless of the retention clock.
The dentist owns the physical record; the patient has a right of access to the information. Provide copies or a summary on a proper request, you may charge a reasonable copying cost, and you may not withhold records because a bill is unpaid.
Privacy: HIPAA permits treatment, payment, and operations uses without authorization, subject to minimum necessary; other uses generally need a valid authorization. California's Confidentiality of Medical Information Act is often stricter, and HIV, substance-use, and mental-health information carry extra protection. Where state and federal law differ, follow the stricter rule.
Traps
- Releasing records to a spouse, employer, or another dentist without patient authorization.
- Assuming HIPAA always controls; California law can be more protective.
- Treating radiographs as something other than part of the record.
- Altering a note after a records request - itself unprofessional conduct.
Rule of thumb
If the request comes from the patient or someone the patient has authorized in writing, release it, document it, and bill only the copying cost.