216-40-05 R.I. Code R. § 2.14

Current through June 20, 2024

Section 216-RICR-40-05-2.14 - Record Keeping and Disclosure

2.14.1. Availability of Dental Records

A. A licensed dentist and/or other licensee shall maintain a dental record for each patient which is adequate to enable the licensee and/or another licensee to provide proper diagnosis and treatment. The dentist shall maintain a patient's written dental record and radiographs (x-rays) for a minimum of five (5) years from the date of the last dental visit, in accordance with R.I. Gen. Laws § 23-3-26, entitled "Vital Records." Records of minors shall be kept for at least five (5) years after such minor will have reached the age of eighteen (18) years. Records shall be maintained in a manner which permits the patient and/or successor dentist access to these records.

B. At a minimum, said records shall be legible and include:

1. The name, address and date of birth of the patient and, if a minor, the name of the parent or guardian and any disclosure statements, authorizations and/ or consent forms;

2. The patient's medical history;

3. A record of results of a clinical examination, where appropriate, or an indication of the patient's chief complaint;

4. A treatment plan, where appropriate;

5. The dates of each patient visit and a description of the treatment or services rendered at each visit;

6. A description of all radiographs taken and of diagnostic models made;

7. The date, dosage and amount of any medication or drug prescribed, dispensed or administered to the patient and Prescription Drug Monitoring Program query results, if appropriate; and,

8. A record of any recommendations or referrals for treatment or consultation by a specialist, including those which were refused by the patient.

C. Upon a patient's written request, a dentist shall provide a patient or another specifically authorized person with a complete copy of and a detailed summary of the patient's dental record, which includes all relevant data.

D. A dentist may charge a reasonable fee for the expense of providing a patient's dental record, not to exceed cost. The dentist shall not require prior payment of charges for dental services as a condition for providing a copy of the dental record.

E. Dentists shall maintain patient confidentiality in the storage and transfer of records pursuant to the provisions of R.I. Gen Laws § 5-37.3, "Confidentiality of Health Care Information Act."

F. A dentist or other licensee treating the patient shall sign or initial the patient's dental record after each procedure or visit.

216 R.I. Code R. § 216-RICR-40-05-2.14

Amended effective 4/4/2019