18 Va. Admin. Code § 60-25-110

Current through Register Vol. 41, No. 4, October 8, 2024

Section 18VAC60-25-110 - [Effective until 10/24/2024] Patient records; confidentiality

A. A dental hygienist shall be responsible for accurate and complete information in patient records for those services provided by a hygienist or a dental assistant under direction to include the following:

1. Patient's name on each page in the patient record;

2. A health history taken at the initial appointment, which is updated when local anesthesia or nitrous oxide/inhalation analgesia is to be administered and when medically indicated and at least annually;

3. Options discussed and oral or written consent for any treatment rendered with the exception of prophylaxis;

4. List of drugs administered and the route of administration, quantity, dose, and strength;

5. Radiographs, digital images, and photographs clearly labeled with the patient's name, date taken, and teeth identified;

6. A notation or documentation of an order required for treatment of a patient by a dental hygienist practicing under general supervision as required in 18VAC60-25-60 C; and

7. Notation of each treatment rendered, date of treatment, and the identity of the dentist and the dental hygienist providing service.

B. A dental hygienist shall comply with the provisions of § 32.1-127.1:03 of the Code related to the confidentiality and disclosure of patient records. A dental hygienist shall not willfully or negligently breach the confidentiality between a practitioner and a patient. A breach of confidentiality that is required or permitted by applicable law or beyond the control of the hygienist shall not be considered negligent or willful.

C. A dental hygienist practicing under remote supervision shall document in the patient record that he has obtained (i) the patient's or the patient's legal representative's signature on a statement disclosing that the delivery of dental hygiene services under remote supervision is not a substitute for the need for regular dental examinations by a dentist and (ii) verbal confirmation from the patient that the patient does not have a dentist of record whom he is seeing regularly.

18 Va. Admin. Code § 60-25-110

Derived From, Virginia Register Volume 32, Issue 05, eff. 12/2/2015; Amended, Virginia Register Volume 33, Issue 04, eff. 11/16/2016; Amended, Virginia Register Volume 34, Issue 01, eff. 10/4/2017.

Statutory Authority: § 54.1-2400 of the Code of Virginia.