I am going to be writing a series of blog posts all about – you guessed it – dental records. What are they? Who owns them? Who can access them? What does the Royal College of Dental Surgeons say about them? What does privacy legislation say about dental records? I’ll go through these and other questions to help educate you about DENTAL RECORDS.
What are Dental Records?
A Dental Record is any information kept about a patient with a dentist or dental clinic.
At a minimum, this information includes the patient’s name, contact information, date of birth, insurance information, primary physician, and emergency contact info. This information should be updated regularly to ensure that it is accurate.
Apart from this basic information, the Royal College of Dental Surgeons of Ontario has guidelines that state that dental records must include the following (and be regularly updated):
- accurate general patient information;
- a medical history;
- a dental history;
- an accurate description of the conditions that are present on initial examination, including an entry such as “within normal limits” where appropriate;
- a record of the significant findings of all supporting diagnostic aids, tests or referrals such as radiographs, study models, reports from specialists;
- a diagnosis and treatment plan;
- a notation that informed consent was obtained from the patient for treatment and, where appropriate, such informed consent appears in writing;
- assurance that patient consent was obtained for the release of any and all patient information to a third party;
- a description of all treatment that is provided, materials and drugs used, and where appropriate, the outcome of the treatment; and
- an accurate financial record.
Why have dental records?
Dental records are necessary to have for legal, ethical, and professional reasons.
To provide excellent dental services and mitigate against negligence claims, it’s important to have complete and accurate dental records. Inaccurate or incomplete records could lead to inappropriate treatment and injury (e.g. prescribing the wrong medication). Dental records are also needed for dentists to show the work they’ve done in order to get paid (e.g. by insurance companies). There is also various legislation that mandates that dental records be kept (e.g. under the Narcotic Control Regulations, which deals with the possession and use of narcotics and targeted substances). Finally, if a dentist were for any reason to become unable to practise, another dentist should be able to easily review the chart and carry on with the care of the patient.