Wash. Admin. Code § 246-812-310

Current through Register Vol. 24-21, November 1, 2024

Section 246-812-310 - Patient record content

(1) A licensed denturist who treats patients shall maintain legible, complete, and accurate patient records.

(2) The patient record must contain clinical records and financial records.

(3) Each clinical record entry must include at least the following information:

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

(b) Identity of practitioner who provided treatment, if treatment was provided;

(c) Date of each patient record entry, document, radiograph, or model;

(d) Physical examination findings documented by subjective complaints, objective findings, an assessment or diagnosis of the patient's condition, and treatment plan;

(e) Treatment plan based on the assessment or diagnosis of the patient's condition;

(f) Up-to-date dental and medical history that may affect treatment;

(g) Any diagnostic aid used including, but not limited to, images, radiographs, and test results, which shall be retained as listed in WAC 246-812-320;

(h) Complete description of all treatment or procedures, or both, provided at each visit;

(i) Referrals and communication to and from health care providers;

(j) Notation of communication to or from patients or patient's parent or guardian, regarding:

(i) Notation of the informed consent discussion indicating potential risk(s) and benefit(s) of proposed treatment, recommended tests, and alternatives to treatment, including no treatment or tests;

(ii) Notation of post-treatment instructions or reference to an instruction pamphlet given to the patient;

(iii) Notation regarding patient complaints or concerns associated with treatment including complaints or concerns obtained in person or by phone, email, or text; and

(iv) Termination of the denturist-patient relationship.

(4) Clinical record entries must not be erased or deleted from the record.

(a) Mistaken handwritten entries must be corrected with a single line drawn through the incorrect information and must be initialed and dated. New or corrected information must be initialed and dated.

(b) If an electronic record, a record audit trail must be maintained that includes a time and date history of deletions, edits, or corrections, or all the above, to electronically signed records.

Wash. Admin. Code § 246-812-310

Adopted by WSR 14-24-033, Filed 11/24/2014, effective 12/25/2014

Amended by WSR 20-04-028, Filed 1/28/2020, effective 2/28/2020