18 Va. Admin. Code § 60-25-110

Current through Register Vol. 41, No. 6, November 4, 2024

Section 18VAC60-25-110 - 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 and documented 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 documented written consent in the patient record 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. No dental hygienist shall 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 the dental hygienist 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 the patient 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; Amended, Virginia Register Volume 41, Issue 2, eff. 10/24/2024.

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