STANDARD 15: Dental Records

15.1 General 

1. A dental record shall be maintained for every individual evaluated or treated in the dental organization.

2. Dental records shall be accurately written, promptly completed, properly filed, retained, and accessible.

3. Dental records shall be retained in their original or legally reproduced form for a period of at least 5 years or in accordance with the national law.

4. Dental records shall be properly stored in secure locations where they are protected from fire, water damage and other threats.

5. The dental record system shall ensure that dental record entries are not lost, stolen, destroyed, altered, or reproduced in an unauthorized manner or accessed by unauthorized personnel.

6. Dental records shall remain confidential and only be released by permission and authorization according to national law.

7. The dental record system shall correctly identify and preserve the identity of the author of every dental record entry.

8. When an electronic medical record (EMR) is in use, the dental organization shall prevent alterations of record entries after they have been authenticated. The EMR shall be immediately available for authorized review and conform to all requirements applying to the dental record herein.

NOTE 1 The term "dental record" includes at least written documents, computerized electronic information, radiology film and scans, laboratory reports and pathology slides, videos, audio recordings, and other forms of information regarding the condition of a patient.

NOTE 2 The right to confidentiality means safeguarding the content of information, including patient identification, paper records, video, audio, and/or computer stored information from unauthorized disclosure without the specific informed consent of the individual, parent of a minor child, or legal guardian. Confidentiality applies to both central records and clinical record information that may be kept at dispersed locations

15.2 Content of Dental Record 

1. The dental record shall contain general patient information with respect to their medical history and physical condition including documentation of medications, allergies, significant co-morbidities likely to modify contemplated therapeutic dental processes, and other significant associated relevant information.

2. All entries shall be legible, complete, dated, and timed. They shall be authenticated by the person responsible for providing care consistent with dental organization policy and national law 3. The dental record shall contain information such as notes, records, reports, recordings, consents, test results, consultations, and other assessments to support the diagnosis and planned procedure. It shall include a summary of the patient’s progress and response.

4. All records shall document complications, healthcare facility acquired infections, and unfavorable reactions to medications and moderate sedation (APPENDIX A) including local anesthetic agents.