S.D. Admin. R. 20:43:11:01

Current through Register Vol. 51, page 57, November 12, 2024

Section 20:43:11:01 - Medical record - Content

A licensed dentist who treats patients shall maintain legible, complete, and accurate medical records. The medical record must contain the clinical records and the financial records. The clinical record must include the following information:

(1) For each clinical record entry note:

(a) The signature, initials, or electronic verification of the individual making the entry note;

(b) If treatment was provided, the name and the signature, initials, or electronic verification of the individual that provided treatment;

(2) The date of each patient record entry, document, radiograph or model;

(3) The examination findings documented by subjective complaints, objective findings, an assessment or diagnosis of the patient's condition, and proposed treatment options;

(4) Current dental and medical history that may affect dental treatment;

(5) Any diagnostic aid used including, but not limited to, images, radiographs, and test results. All film or digital radiographs must be of diagnostic quality. Retention of molds or study models is at the discretion of the dentist, except for molds or study models for orthodontia or full mouth reconstruction which shall be retained as part of the clinical record;

(6) An agreed upon treatment plan based on the assessment or diagnosis of the patient's condition;

(7) A complete description of all treatment or procedures administered at each visit;

(8) A record of any medication administered or dispensed in office, or prescribed, including:

(a) The date administered, dispensed, or prescribed;

(b) The name of the patient administered, dispensed, or prescribed to;

(c) The name of the medication; and

(d) The dosage and amount of the medication administered, dispensed, or prescribed, including refills;

(9) Referrals, patient response to referrals, and any communication to and from any health care provider;

(10) Notation of communication to and from the patient or patient's parent or guardian, including:

(a) Notation of the informed consent discussion, including a discussion of potential risks and benefits of proposed treatment, recommended tests, and alternatives to treatment, including no treatment or tests;

(b) Notation of posttreatment instructions or reference to an instruction pamphlet given to the patient;

(c) Notation regarding patient complaints or concerns associated with treatment, including complaints or concerns obtained in person, by phone call, mail, electronic communication, or digital communication; and

(d) Termination of doctor-patient relationship; and

(11) A copy of, or notation regarding, each laboratory order.

S.D. Admin. R. 20:43:11:01

50 SDR 125, effective 5/8/2024

General Authority: SDCL 36-6A-14(20).

Law Implemented: SDCL 36-6A-1(6), 36-6A-14(1).