Md. Code Regs. 10.44.30.03

Current through Register Vol. 52, No. 1, January 10, 2025

Section 10.44.30.03 - Clinical Charts

Each patient's clinical chart shall include at a minimum the following:

A. Patient's name and date of treatment;

B. Reasons for the patient's visit;

C. Treatment plans that are signed and dated by both the treating dentist and the patient;

D. Patient's complaints;

E. Diagnosis and treatment notes;

F. Progress notes;

G. Post operative instructions;

H. Study models;

I. In-person conversations, telephone conversations, and other correspondence with the patient or their representative;

J. Identification of medications prescribed, administered, dispensed, quantity, and directions for use;

K. Clinical details with regard to the administration of:

(1) Nitrous oxide;

(2) Anxiolytics;

(3) Sedation; and

(4) General anesthesia.

L. Radiographs of diagnostic quality;

M. Periodontal charting;

N. Laboratory work authorization forms and correspondence to and from laboratories;

O. Informed consent;

P. Copies of correspondence and reports provided to other health care providers, diagnostic facilities, and legal representatives;

Q. Records and reports provided by other health care providers and diagnostic facilities;

R. Details regarding referrals and consultations;

S. Patient complaints pertaining to the dentist and staff, and their manner of resolution;

T. Noncompliance and missed appointment notes; and

U. Dismissal letter.

Md. Code Regs. 10.44.30.03