Minnesota Administrative Rules

3100.9600 RECORD KEEPING.

Subpart 1.

Definitions.

For the purposes of this part, "patient" means a natural person who has received dental care services from a provider for treatment of a dental condition. In the case of a minor who has received dental care services pursuant to Minnesota Statutes, sections 144.341 to 144.347, patient includes a parent or guardian, or a person acting as a parent or guardian in the absence of a parent or guardian.

Subp. 2.

Dental records.

Dentists shall maintain dental records on each patient. The records must contain the components specified in subparts 3 to 10.

Subp. 3.

Personal data.

Dental records must include at least the following information:

A.

the patient's name;

B.

the patient's address;

C.

the patient's date of birth;

D.

if the patient is a minor, the name of the patient's parent or guardian;

E.

the name and telephone number of a person to contact in case of an emergency; and

F.

the name of the patient's insurance carrier and insurance identification number, if applicable.

Subp. 4.

Patient's reasons for visit.

When a patient presents with a chief complaint, dental records must include the patient's stated oral health care reasons for visiting the dentist.

Subp. 5.

Dental and medical history.

Dental records must include information from the patient or the patient's parent or guardian on the patient's dental and medical history. The information must include a sufficient amount of data to support the recommended treatment plan.

Subp. 6.

Clinical examinations.

When emergency treatment is performed, items A to C pertain only to the area treated. When a clinical examination is performed, dental records must include:

A.

recording of existing oral health care status;

B.

any radiographs used; and

C.

the facsimiles or results of any other diagnostic aids used.

Subp. 7.

Diagnosis.

Dental records must include a diagnosis.

Subp. 8.

Treatment plan.

Dental records must include an agreed upon written and dated treatment plan except for routine dental care such as preventive services. The treatment plan must be updated to reflect the current status of the patient's oral health and treatment.

Subp. 9.

Informed consent.

Dental records must include a notation that:

A.

the dentist, advanced dental therapist, dental therapist, dental hygienist, or licensed dental assistant discussed with the patient the treatment options and the prognosis, benefits, and risks of each treatment that is within the scope of practice of the respective licensee; and

B.

the patient has consented to the treatment chosen.

Subp. 10.

Progress notes.

Dental records must be legible and include a chronology of the patient's progress throughout the course of all treatment and postoperative visits. The chronology must include:

A.

all treatment provided;

B.

all medications used and materials placed;

C.

the treatment provider by license number, name, or initials; and

D.

when applicable, the identity of the collaborating dentist authorizing treatment by license number.

Subp. 11.

Corrections of records.

Notations must be legible, written in ink, and contain no erasures or "white-outs." If incorrect information is placed in the record, it must be crossed out with one single line and initialed by a dental health care worker.

Subp. 12.

Retention of records.

A dentist shall maintain a patient's dental records for at least seven years beyond the time the dentist last treated the patient. In the case of a minor patient, a dentist shall maintain a patient's dental records for at least seven years past the age of majority.

Subp. 13.

Transfer of records.

A patient's dental records must be transferred according to Minnesota Statutes, sections 144.291 to 144.298, irrespective of the status of the patient's account. Digital radiographs shall be transferred by compact or optical disc, electronic communication, or printing on high-quality photographic paper. All transferred film or digital radiographs must reveal images of diagnostic quality using proper exposure settings and processing procedures.

Subp. 14.

Electronic record keeping.

A.

The requirements of subparts 1 to 13 apply to electronic record keeping as well as to record keeping by any other means.

B.

When electronic records are kept, a dentist must keep either a duplicate hard copy record or use an unalterable electronic record.

Statutory Authority:

MS s 144.335; 150A.04; 150A.08

History:

21 SR 1730; L 2007 c 147 art 10 s 15; 35 SR 459; 36 SR 738; 37 SR 1849; 39 SR 1455

Published Electronically:

May 7, 2015