Code of Massachusetts Regulations › 234 CMR - BOARD OF REGISTRATION IN DENTISTRY › Title 234 CMR 5.00 - REQUIREMENTS FOR THE PRACTICE OF DENTISTRY, DENTAL HYGIENE, AND DENTAL ASSISTING › Section 5.13 - Patient Records, Confidentiality, Retention, and Availability

Current through Register 1525, July 5, 2024
(1)
Content of Patient
			 Record
. Patient records include, but are not limited to, dental
			 charts, photographs, patient histories, examination and test results,
			 diagnoses, treatment plans, progress notes, anesthesia charts, orthodontic
			 models, prescriptions, radiographs, patient consents, and billing
			 records.
(2)
Confidentiality of Patient Records
. All patient
			 records including, but not limited to, dental charts, photographs, patient
			 histories, examination and test results, diagnoses, treatment plans, progress
			 notes, anesthesia charts, orthodontic models, prescriptions, radiographs,
			 patient consents, and billing records of any patient treated shall be
			 maintained in a manner that ensures confidentiality and access for patients and
			 authorized practitioners who may wish to obtain a copy of patient
			 records.
(3)
Record
			 Retention Requirement
. The licensee shall maintain a patient's
			 original dental record and original radiographs (x-rays) for a minimum of seven
			 years from the date of the last patient treatment. In addition, the patient
			 record of a minor shall be retained for a minimum of seven years from the date
			 of the last patient treatment or three years from when the patient has reached
			 the age of majority, whichever is later.
(4)
Availability of Dental
			 Records
.
(a)
Request
			 for Copy of Dental Record
. The licensee shall provide upon request
			 by a patient or another specifically authorized person, a complete copy of the
			 patient's dental record in accordance with M.G.L. c. 112, § 12CC. A copy
			 of the patient record, including radiographs, shall be provided within a
			 reasonable amount of time not to exceed 30 calendar days from the date of the
			 request. The licensee may charge a reasonable fee for the expense of providing
			 a patient's dental record, not to exceed the cost of either labor and/or
			 materials incurred in the copying of the patient record, radiographs and
			 models. The licensee shall not require payment for dental services rendered as
			 a condition of providing a copy of the dental record. A dentist may offer to
			 provide the patient with a summary of the patient's record, but the summary
			 shall not be in lieu of the complete patient record if requested.
(b)
Treatment in a School
			 Setting
. Where consent has been granted by the patient or legal
			 representative, a copy of the patient's Information Sheet or other written
			 summary of the screening, examination, or treatment shall be provided to the
			 official designated by the school.
(c)
Treatment in a Nursing Home
			 or Residential Treatment Facility
. A copy of the patient's
			 information sheet or other written summary of the screening, examination, or
			 treatment shall be provided to the official designated by the facility or
			 institution and shall be made part of the patient record maintained by the
			 nursing home or residential facility.
(d) If the licensee dies and the practice is
			 closed, the estate may notify patients treated within the two years prior to
			 the date of passing. Said notice shall inform patients of how they may obtain a
			 copy of their patient record, including radiographs. Notice may be by a written
			 letter to each patient, by electronic notice, public notice in the appropriate
			 newspaper, and/or by other means which is widely disseminated. A copy of said
			 notice must be submitted to the Board upon issuance and/or
			 publication.
(e) Electronic patient
			 records shall comply with the requirements of 234 CMR 5.13 and
			 5.14
			 and shall be unalterable and producible in paper form upon request.