Written Dental Records; Minimum Content; Retention  

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    DEPARTMENT OF HEALTH

    Board of Dentistry

    RULE NO.:RULE TITLE:

    64B5-17.002Written Dental Records; Minimum Content; Retention

    NOTICE OF CHANGE

    Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 40 No. 243, December 17, 2014 issue of the Florida Administrative Register.

    The Notice of Proposed Rule was a substantial rewording of the text. The change is in response to written comments submitted by the staff of the Joint Administrative Procedures Committee and by a vote by the Board at the meeting held on February 20, 2015.  The changes are as follows:

     

    64B5-17.002 Written Dental Records; Minimum Content, Retention.

    A licensed dentist shall maintain patient dental records in a legible manner and with sufficient detail to clearly demonstrate why the course of treatment was undertaken.

    (1) Dental Record: The dental record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment and document the course and results of treatment accurately, by including, at a minimum, patient histories; (X rays if taken), examination results; test results; records of drugs prescribed, dispensed, or administered; reports of consultation or referrals; and copies of records or reports or other documentation obtained from health care healthcare practitioners at the request of the dentist and relied upon by the dentist in determining the appropriate treatment of the patient.

    (2) No change.

    (3) Record Transfer or Release: Whenever patient records are released or transferred, the dentist releasing or transferring the records shall maintain either the original records or copies thereof and a notation shall be made in the retained records indicating to whom the records were released or transferred and the authority for such release. Transfer of records in a multidentist practice multi-practice dental office shall be done and documented in strict accordance with Section 466.018, F.S.

    (4) No change.

    (5) Appointment Book: Each licensed dentist shall retain a copy of each entry in his or her patient appointment book or such other log, calendar, book, file or computer data, used in lieu of an appointment book, for a period of no less than four (4) years from the date of each entry thereon.

    (6) Dentist of Record: All records that are required by this rule and any other patient record shall be properly annotated to identify the dentist of record.  The dentist of record is the dentist who:

    (a) through (c) No change.

    (d) If the dentist of record is not identifiable, then the owner of the dental practice in which the patient was treated is the dentist of record. If there has been more than one provider of treatment and neither paragraph (a) or (b) or (c) can be determined with reasonable certainty, the dentist of record reverts entirely back to the Florida licensed owner dentist of the dental practice in which the dental patient is seen or treated.

    (7) Owner of Dental Practice: All dental records required by this rule and any additional records maintained in the course of practicing dentistry shall be the property of the Florida licensed owner dentist of the dental practice in which the dental patient is seen or treated and the owner dentist shall be ultimately responsible for all record keeping requirements set forth by statute or rule.

    (a) The Florida licensed owner dentist is responsible for the records of patients seen or treated by any employee, associate, or visiting dentist.

    (b) through (c) No change.

    (8) through (9) No change.

    Rulemaking Authority 466.004(4) FS. Law Implemented 456.057, 456.058, 466.028(1)(m), (o), 466.018 FS. History–New 10-8-85, Formerly 21G-17.02, Amended 10-28-91, Formerly 21G-17.002, Amended 11-22-93, Formerly 61F5-17.002, 59Q-17.002, Amended 11-15-99, 4-22-03, 3-14-13,                                  .

     

    THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Susan Foster, Executive Director, Board of Dentistry, 4052 Bald Cypress Way, Bin #C08, Tallahassee, Florida 32399-3258