Ala. Admin. Code r. 270-X-2-.22

Current through Register Vol. 43, No. 02, November 27, 2024

Section 270-X-2-.22 - [Effective 1/11/2025] Patient Records

(1) A dentist shall maintain complete records on all patients and said records may include such information as the dentist deems appropriate but shall at a minimum include the following:

(a) Patient's first and last name, address, and contact information; and,

(b) Current health history; and,

(c) The date treatment rendered. The type of treatment rendered. The reason for the treatment rendered and the full name of the treating dentist and/or dental hygienist; and,

(d) Records of financial transactions should be retained or recorded; and,

(e) Applicable radiographs and/or digital intraoral images; and,

(f) Correspondence between treating dentist and any prior and subsequent dentists, physicians and/or referral sources/recommendations; and,

(g) Pathology reports and all related correspondence; and

(h) A record of all controlled substances prescribed, administered, and/or dispensed, including dosages, quantities, and authorized refills, if any.

(2) When appropriate, records may also include but not be limited to:

(a) Treatment plan(s); and,

(b) Informed consent(s).

(3) Records shall be maintained in accordance with Rule 270-X-2-.26.

Ala. Admin. Code r. 270-X-2-.22

New Rule Filed: March 15, 2006; effective April 19, 2006. Amended: Filed February 22, 2012; effective March 28, 2012. Amended: Filed April 17, 2013; effective May 22, 2013.

Amended by Alabama Administrative Monthly Volume XLIII, Issue No. 02, November 27, 2024, eff. 1/11/2025.

Author: Board of Dental Examiners of Alabama

Statutory Authority:Code of Ala. 1975, § 34-9-43.