N.J. Admin. Code § 13:30-8.7

Current through Register Vol. 56, No. 24, December 18, 2024

Section 13:30-8.7 - Patient records

(a) A contemporaneous, permanent patient record shall be prepared and maintained by a licensee for each person seeking or receiving dental services, regardless of whether any treatment is actually rendered or whether any fee is charged. Licensees shall also maintain records relating to charges made to patients and third-party carriers for professional services. All treatment records, bills, and claim forms shall accurately reflect the treatment or services rendered. Such records shall include, at a minimum:

1. The name, address, and date of birth of the patient and, if a minor, the name of the parent or guardian;

2. The patient's medical history;

3. A record of results of a clinical examination where appropriate or an indication of the patient's chief complaint;

4. A diagnosis and a treatment plan, which shall also include the material treatment risks and clinically acceptable alternatives, and costs relative to the treatment that is recommended and/or rendered;

5. The dates of each patient visit and an accurate description of all treatment or services rendered and the materials used at each visit;

6. Radiographs, if any, of a diagnostic quality and a description of all diagnostic models made, identified with the patient's name and the date. If the radiographs are sent out of the dental office, the dentist shall retain the originals or a diagnostic copy of the radiographs in the patient record;

7. The date and a description of any medications prescribed, dispensed or sold including the dosage or a copy of any written prescriptions;

8. Copies of any prescriptions to laboratories for dental prostheses;

9. Complete financial data concerning the patient's account, including each amount billed to or received from the patient or third party payor and the date of each such bill and payment;

10. Copies of all claim forms submitted to third party payors by a licensee or the licensee's agent or employee;

11. Payment vouchers received from third party payors;

12. A record of any recommendations or referrals for treatment or consultation by a specialist, including those which were refused by the patient;

13. The name of the dentist of record consistent with the requirements of N.J.A.C. 13:30-8.15; and

14. If written notations appear in the patient record, the notations shall be legible, written in ink and contain no erasures or white-outs. If incorrect information is placed in the record, it shall be crossed out with a single non-deleting line and shall be initialed and dated by the licensee on the date the change was made. If additions are made to the record, the additions shall be initialed and dated by the licensee on the date the change was made.

(b) Each dentist or dental auxiliary shall sign or initial each entry on the patient record pertaining to the treatment he or she rendered. If no such signature or initialing appears on the patient record, it shall be presumed that such treatment was rendered by the dentist of record, unless the latter shall establish, to the satisfaction of the Board, the identity of the individual who rendered such treatment.

(c) A patient record may be prepared and maintained on a personal or other computer provided that the licensee complies with all of the following requirements:

1. The licensee shall use a computer system which contains an internal, permanently activated date recordation for all entries;

2. The computer system shall have the capability to print on demand a hard copy of all current and historical data contained in each patient record file;

3. The licensee shall identify each patient record by the patient's name and at least one other form of identification so that the record may be readily accessed;

4. The licensee shall post record entries at least once a month so that the entries are permanent and cannot be deleted or altered in any way. The licensee may subsequently make a new entry to indicate a correction to a permanent entry, provided that the new entry generates a permanent audit trail which is maintained in the patient record. The audit trail shall show the original entry, the revised entry, the date of the revised entry, the reason for the change and the identity of the person who authorized the change;

5. The licensee shall prepare a back-up of all computerized patient records at least quarterly, except that if a licensee changes computer systems or software programs, the licensee shall prepare a backup as of the last date when the system to be replaced shall be used.

i. For purposes of this section, "back-up" shall include data files and the software programs required to retrieve those files including the operating system and the program file.

ii. The back-ups shall be clearly dated and marked with an external label as "Back-up of computerized data as of (date)."

iii. The licensee shall maintain and store at least the last three quarterly back-ups onsite.

iv. The licensee shall maintain and store the fourth quarter (annual) back-up offsite;

6. The licensee shall provide to the Board upon request any back-up data maintained off premises, together with the following information:

i. The name of the computer operating system containing the patient record files and instructions on using such system;

ii. Current passwords;

iii. Previous passwords if required to access the system; and

iv. The name of a contact person at the practice management company, if any, that provides technical support for the licensee's computer system; and

7. Electronic records shall comply with the Federal Health Insurance Portability and Accountability Act of 1996 and the Federal health privacy rule set forth at 45 CFR Parts 160 and 164.

(d) Patient records, including all radiographs, shall be maintained for at least seven years from the date of the last entry, except that diagnostic and study models used for definitive treatment shall be maintained for at least three years from the date the model is made.

(e) Licensees shall provide patient records to the patient or the patient's authorized representative or another dentist of the patient's choosing in accordance with the following:

1. Upon receipt of a written request from a patient or the patient's authorized representative and within 14 days thereof, legible copies of the patient record including, if requested, duplicates of models and copies of radiographs, shall be furnished to the patient, the patient's authorized representative, or a dentist of the patient's choosing. "Authorized representative" means a person who has been designated by the patient or a court to exercise rights under this section. An authorized representative shall include the patient's attorney or an agent of an insurance carrier with whom the patient has a contract which provides that the carrier be given access to records to assess a claim for monetary benefits or reimbursement. If the patient is a minor, a parent or guardian who has custody (whether sole or joint) shall be deemed an authorized representative.

2. A licensee may require any unpaid balance for diagnostic services only to be paid prior to release of such records. Where treatment of a patient whose dental expenses are paid through Medicaid is discontinued by the dentist prior to completion of the treatment, no charge for the records shall be made, nor shall any payment be required.

3. The licensee may charge a reasonable fee for:

i. The reproduction of records, which shall be no greater than $ 1.00 per page or $ 100.00 for the entire record, whichever is less. (If the record requested is less than 10 pages, the licensee may charge up to $ 10.00 to cover postage and the miscellaneous costs associated with retrieval of the record.); and/or

ii. The reproduction of radiographs or any other material within a patient record, which cannot be routinely copied or duplicated on a commercial duplicating machine. The fee for duplication for a set of up to nine radiographs shall not exceed $ 15.00. The fee for duplication for a set of up to 18 radiographs shall not exceed $ 30.00. The fee for duplication of a panorex shall not exceed $ 30.00.

4. Licensees shall not charge a patient for a copy of the patient's record when the licensee has affirmatively terminated a patient from the practice.

5. To the extent that the record is illegible or prepared in a language other than English, the licensee shall provide a typed or written transcription and/or translation at no additional cost to the patient.

(f) Licensees shall maintain the confidentiality of patient records, except that:

1. The licensee shall release patient records as directed by the Board of Dentistry or the Office of the Attorney General, or by a Demand for Statement in Writing under Oath, pursuant to N.J.S.A. 45:1-18. Such records shall be originals, unless otherwise specified, and shall be unedited, with full patient names. To the extent that the record is illegible, the licensee, upon request, shall provide a typed or written transcription of the record. If the record is in a language other than English, the licensee shall also provide a translation. All radiographs, models, and reports maintained by the licensee, including those prepared by other dentists, shall also be provided. The costs of producing such records shall be borne by the licensee.

2. The licensee, in the exercise of professional judgment and in the best interests of the patient (even absent the patient's request), may release pertinent information about the patient's treatment to another licensed health care professional who is providing or who has been asked to provide treatment to the patient, or whose expertise may assist the licensee in his or her rendition of professional services.

3. The licensee shall release information as required by statute or rule, such as the reporting of communicable diseases or gunshot wounds or suspected child abuse, or when the patient's treatment is the subject of peer review.

(g) If a licensee ceases to engage in the practice of dentistry or it is anticipated that he or she will remain out of practice for more than six months, the licensee or a designee shall:

1. Establish a procedure by which patients may obtain treatment records or agree to the transfer of those records to another licensee who is assuming the responsibilities of that practice;

2. If the practice will not be attended by another licensee, publish a notice of the cessation and the established procedure for the retrieval of records in a newspaper of general circulation in the geographic location of the licensee's practice, at least once each month for the first three months after the cessation;

3. File a notice of the established procedure for the retrieval of records with the Board of Dentistry;

4. Make reasonable efforts to directly notify any patient treated during the six months preceding the cessation of the practice to provide information concerning the established procedure for retrieval of records; and

5. Conspicuously post a notice on the premises of the procedure for the retrieval of records.

(h) Patient records need not be maintained in situations where no patient-dentist relationship exists, such as where the professional services of a dentist are rendered at the behest of a third party for the purposes of examination and evaluation only, at the behest of the Board or for dental screenings.

(i) Services not recorded in the patient record in accordance with the requirements of this section shall be presumed not to have been performed. It shall be the responsibility of the licensee to produce evidence to establish that the non-recorded services were actually performed.

N.J. Admin. Code § 13:30-8.7

New Rule, R.1980 d.457, effective 10/16/1980.
See: 12 N.J.R. 347(a), 12 N.J.R. 672(f).
Amended by R.1986 d.269, effective 7/7/1986.
See: 18 N.J.R. 816(a), 18 N.J.R. 1394(a).
Added text to (c) "provided, however, where ... or payment required."
Amended by R.1990 d.205, effective 4/2/1990.
See: 22 N.J.R. 149(b), 22 N.J.R. 1145(a).
Repeal and New Rule, R.1993 d.650, effective 12/20/1993.
See: 25 N.J.R. 1833(a), 25 N.J.R. 5935(a).
Amended by R.1998 d.90, effective 2/17/1998.
See: 29 N.J.R. 4069(b), 30 N.J.R. 686(a).
Rewrote (a)8; inserted new 9 and 10; recodified existing 9 as 11; added a new (b); recodified existing (b) as (c) and added language regarding models; and recodified existing (c) through (f) as (d) through (g).
Amended by R.2000 d.147, effective 4/3/2000.
See: 32 N.J.R. 215(a), 32 N.J.R. 1221(a).
In (a), deleted "where appropriate" at the end of 4, rewrote 6, and substituted "and" for "or" following "dosage" in 7; in (b)5, substituted "quarterly" for "quarterly-annually" following "at least" in the introductory paragraph, and deleted ", but not limited to," following "including" in i; in (d), inserted "of the patient's choosing" following "dentist" throughout 1, and inserted "or written" following "typed" in the last sentence of 3; in (e), inserted "or written" following "typed" in the third sentence of 1; in (f)5, deleted "when possible" at the end; and rewrote (g).
Amended by R.2005 d.309, effective 9/19/2005.
See: 37 N.J.R. 1149(a), 37 N.J.R. 3709(a).
In (a), added 4, deleted "and" at the end of 10, added "; and" and removed "." at the end of 11, added 12; added (b); recodified former (b) as (c); recodified and rewrote former (c) as (d); recodified and rewrote former (d) as (e); recodified former (e)-(g) as (f)-(h).
Amended by R.2011 d.041, effective 2/7/2011.
See: 42 N.J.R. 2217(a), 43 N.J.R. 310(a).
In the introductory paragraph of (a), substituted "third-party" for "third party"; in (a)5, substituted "an accurate" for "a", "all" for "the", and inserted "and the materials used"; rewrote (a)6; added new (a)8; recodified former (a)8 through (a)12 as (a)9 through (a)13; in (a)12, deleted "and" from the end; in (a)13, substituted "; and" for a period at the end; added (a)14; rewrote (e)3ii; in (h), substituted a comma for "or" following "only", and inserted "or for dental screenings"; and added (i).

Amended by 53 N.J.R. 619(c), effective 4/19/2021