Patient Records
Record content
Patient records must be accurate, legible, contemporaneous, and complete enough for another provider to continue care. They include history, diagnosis, treatment plan, progress notes, informed consent, medications, radiographs, lab cases, and communications. Corrections must be dated and attributed; do not erase or backdate.
Retention and access
Board rules set a retention period; HIPAA and civil practice may require longer. Patients generally have a right to inspect and obtain copies, with limited exceptions. Minors' records and guardianship need careful handling. Transfer requests should be honored promptly and may require a reasonable fee. Document verbal consent and any refusal of treatment.
Worked example
A patient requests copies of her radiographs and progress notes. The office says the dentist "owns" the images and refuses. The reasoning: ownership of the physical medium does not defeat the patient's access right. The office should provide copies or a summary under the applicable rule and law, and document the request.
Traps
- Altering a record after a complaint.
- Recording only the procedure and omitting the assessment or consent.
- Missing retention deadlines for adults and minors.
- Releasing records without proper authorization.