Recordkeeping, documentation, and confidentiality
What a defensible record contains
Maryland dental records should be accurate, legible, contemporaneous, and complete. Document the date, patient identity, clinical findings, services performed, anesthesia or medication, supervision level when relevant, patient education, informed consent, referrals, and any refusal of care. Keep radiographs, charting, and correspondence. Correct errors with a dated addendum; never alter or backdate an entry. Retain records for at least the period required by Maryland law, commonly at least five years after the last treatment, and longer for minors or pending claims.
Confidentiality and release
Patient records are confidential. Release them with a valid written authorization, for treatment coordination, or as required by law. HIPAA limits uses and disclosures and requires safeguards. Do not share passwords, leave charts visible, or transmit records through insecure channels. A patient may request access and amendment under the applicable rules.
Worked example
A hygienist realizes she forgot to chart that the patient declined fluoride. She should add a late entry dated today, stating “addendum: patient declined fluoride after education,” rather than squeezing it into yesterday's note. If the record was already released, she should follow the practice's amendment and notification policy.
Traps that cost marks
Do not chart opinions as facts or use vague entries like “cleaned.” Do not destroy records during a complaint or lawsuit. Do not release records without authorization or a legal exception.