Or. Admin. Code § 818-012-0070

Current through Register Vol. 63, No. 11, November 1, 2024

Section 818-012-0070 - Patient Records

(1) Each licensee shall have prepared and maintained an accurate and legible record for each person receiving dental services, regardless of whether any fee is charged. The record shall contain the name of the licensee rendering the service and include:

(a) Name and address and, if a minor, name of guardian;

(b) Date description of examination and diagnosis;

(c) An entry that informed consent has been obtained and the date the informed consent was obtained. Documentation may be in the form of an acronym such as "PARQ" (Procedure, Alternatives, Risks and Questions) or "SOAP" (Subjective Objective Assessment Plan) or their equivalent.

(d) Date and description of treatment or services rendered;

(e) Date, description and documentation of informing the patient of any recognized treatment complications;

(f) Date and description of all radiographs, study models, and periodontal charting;

(g) Health history; and

(h) Date, name of, quantity of, and strength of all drugs dispensed, administered, or prescribed.

(2) Each licensee shall have prepared and maintained an accurate record of all charges and payments for services including source of payments.

(3) Each licensee shall maintain patient records and radiographs for at least seven years from the date of last entry unless:

(a) The patient requests the records, radiographs, and models be transferred to another licensee who shall maintain the records and radiographs;

(b) The licensee gives the records, radiographs, or models to the patient; or

(c) The licensee transfers the licensee's practice to another licensee who shall maintain the records and radiographs.

(4) When a dental implant is placed the following information must be given to the patient in writing and maintained in the patient record:

(a) Manufacture brand;

(b) Design name of implant;

(c) Diameter and length;

(d) Lot number;

(e) Reference number;

(f) Expiration date;

(g) Product labeling containing the above information may be used in satisfying this requirement.

(5) When changing practice locations, closing a practice location or retiring, each licensee must retain patient records for the required amount of time or transfer the custody of patient records to another licensee licensed and practicing dentistry in Oregon. Transfer of patient records pursuant to this section of this rule must be reported to the Board in writing within 14 days of transfer, but not later than the effective date of the change in practice location, closure of the practice location or retirement. Failure to transfer the custody of patient records as required in this rule is unprofessional conduct.

(6) Upon the death or permanent disability of a licensee, the administrator, executor, personal representative, guardian, conservator or receiver of the former licensee must notify the Board in writing of the management arrangement for the custody and transfer of patient records. This individual must ensure the security of and access to patient records by the patient or other authorized party, and must report arrangements for permanent custody of patient records to the Board in writing within 90 days of the death of the licensee.

Or. Admin. Code § 818-012-0070

DE 9-1984, f. & ef. 5-17-84; DE 1-1988, f. 12-28-88, cert. ef. 2-1-89, DE 1-1989, f. 1-27-90, cert. ef. 2-1-90; Renumbered from 818-011-0060; DE 1-1990, f. 3-19-90, cert. ef. 4-2-90; OBD 7-2001, f. & cert. ef. 1-8-01; OBD 2-2016, f. 11-2-16, cert. ef. 3/1/2017; OBD 2-2019, amend filed 10/29/2019, effective 1/1/2020; OBD 1-2021, amend filed 11/08/2021, effective 1/1/2022

Statutory/Other Authority: ORS 679

Statutes/Other Implemented: ORS 679.140(1)(e) & 679.140(4)