21 N.C. Admin. Code 16T.0101

Current through Register Vol. 39, No. 11, December 2, 2024

Section 16T .0101 - RECORD CONTENT

A dentist shall maintain treatment records on all patients for a period of 10 years from the last treatment date, except that work orders must only be maintained for a period of two years. Treatment records may include such information as the dentist deems appropriate but shall include:

(1) the patient's full name, address, and treatment dates;

(2) the patient's emergency contact or responsible party;

(3) a current health history;

(4) the diagnosis of condition;

(5) the treatment rendered and by whom;

(6) the name and strength of any medications prescribed, dispensed, or administered along with the quantity and date provided;

(7) the work orders issued;

(8) the treatment plans for patients of record, except that treatment plans are not required for patients seen only on an emergency basis;

(9) the diagnostic radiographs, orthodontic study models, and other diagnostic aids, if taken;

(10) the patient's financial records and copies of all insurance claim forms;

(11) the rationale for prescribing each narcotic; and

(12) A written record that the patient gave informed consent consistent with Rule .0103 of this Section.

21 N.C. Admin. Code 16T .0101

Authority G.S. 90-28; 90-48;
Eff. October 1, 1996;
Amended Eff. May 1, 2016; July 1, 2015;
Readopted Eff. January 1, 2019.

Authority G.S. 90-28; 90-48;
Eff. October 1, 1996.

Amended by North Carolina Register Volume 30, Issue 03, August 03, 2015 effective 7/1/2015.

Amended by North Carolina Register Volume 30, Issue 23, June 1, 2016 effective 5/1/2016.

Readopted by North Carolina Register Volume 33, Issue 15, February 1, 2019 effective 1/1/2019.