The subject of whether a profession should define for its members in law what constitutes medical records is always a timely topic for discussion. Some professions do not address the issue directly but rather leave it up to the professional schools to teach the subject of "what should be in the record?" Generally, speaking records need to be legible and detailed enough to show why a particular course of treatment was taken. Recently, the Florida Board of Dentistry, reviewed a draft proposed rule outlining minimum content and retention standards for dental records. The proposed rule states:
64B5-17.002 Written Dental Records; Minimum Content, Retention.
A licensed dentist shall maintain patient dental records in a legible manner and with sufficient detail to clearly demonstrate why the course of treatment was undertaken.
(1) Dental Record: The dental record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment and document the course and results of treatment accurately, by including, at a minimum, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; reports of consultation or referrals; and copies of records or reports or other documentation obtained from healthcare practitioners at the request of the dentist and relied upon by the dentist in determining the appropriate treatment of the patient.
(2) Record Alterations: Any additions, corrections, modifications, annotations, or alterations (hereinafter “change”) to the original dental record entry must be clearly noted as such and must include the date when the change was made, must be initialed by the person making the change, and must have an explanation for the change. An original entry to the record cannot be partially or wholly removed. Rather, to represent the deletion of a record entry, the entry must be struck through where it will remain legible. A change made on the same date of the original entry must also include the time of change.
(3) Record Transfer or Release: Whenever patient records are released or transferred, the dentist releasing or transferring the records shall maintain either the original records or copies thereof and a notation shall be made in the retained records indicating to whom the records were released or transferred and the authority for such release. Transfer of records in a multi-practice dental office shall be done and documented in strict accordance with Section 466.018, F.S.
(4) Record Retention Period: A dentist shall maintain the written dental record of a patient for a period of at least four (4) years.
(a) The four (4) year retention period shall be calculated from the date the patient was last examined or treated by the dentist.
(b) Upon the death of the dentist, the retention provisions of Rule 64B5-17.001, F.A.C., are controlling.
(5) Appointment Book: Each licensed dentist shall retain a copy of each entry in his or her patient appointment book or such other log, calendar, book, file or computer data, used in lieu of an appointment book, for a period of no less than four (4) years from the date of each entry thereon.
(6) Dentist of Record: All records that are required by this rule and any other patient record shall be properly annotated to identify the dentist of record. The dentist of record is the dentist who:
(a) Is identified and noted in the patient record as the dentist of record;
(b) Provides a specific treatment or service and is noted in the patient record as the dentist of record for that treatment or service;
(c) If there has been more than one provider of treatment, is the dentist who places the final restoration, does the surgical procedure, makes the diagnosis or finishes the service or procedure in question; or
(d) If there has been more than one provider of treatment and neither paragraph (a) or (b) or (c) can be determined with reasonable certainty, the dentist of record reverts entirely back to the Florida licensed owner dentist of the dental practice in which the dental patient is seen or treated.
(7) Owner of Dental Practice: All dental records required by this rule and any additional records maintained in the course of practicing dentistry shall be the property of the Florida licensed owner dentist of the dental practice in which the dental patient is seen or treated and the owner dentist shall be ultimately responsible for all record keeping requirements set forth by statute or rule.
(a) The Florida licensed owner dentist is responsible for the records of patients seen or treated by any employee, associate, or visiting dentist.
(b) Multiple owners are severally and equally responsible for the records of patients seen or treated with the dental practice of that dental group.
(c) A lessor or owner dentist is not responsible for the records of an independent dentist who is merely leasing or renting space or staff services for the operation of a separate dental practice within the owner dentist’s physical facility.
(8) Electronic Dental Records: Patient records may be kept in an electronic format, provided that the dentist maintains a back-up copy of information stored in the back-up data processing system using disk, tape, or other secure electronic back-up system, on site or off site, as long as the back-up system is updated in a time frame that does not exceed seventy-two hours (72 hrs.), to assure that data is not lost due to system failure. Any electronic data system must be capable of producing a hard copy on lawful demand in accordance with and pursuant to federal or state laws and rules.
(9) Pro-Bono Dental Events: The Board of Dentistry encourages the provision of pro-bono dental screenings though organized events such as Dental Health Screenings and Give Kids a Smile Program. A strict interpretation of this rule would preclude such efforts to the detriment of the public. Therefore, the Board deems that any records generated as a result of such limited, one-time pro-bono dental screenings, examinations, or treatments through organized events should be consistent with the nature and scope of the services rendered, should be provided to the recipient or guardian and will not result in the dentist performing such services becoming the dentist of record. The minimum content and record retention set forth in this rule shall not govern or be required. When the dentist performs such examinations or treatments each recipients or guardian shall be informed in writing of the following:
(a) The limitation of the screening to one-time dental examination and treatment that can reasonably be performed on the same day of screening. In addition, such examinations or treatments would or would not reasonably require follow-up treatment;
(b) The results of the screening examination or treatments; and
(c) That the screening is not representative of or a substitute for a comprehensive dental examination.
Rulemaking Authority 466.004(4) FS. Law Implemented 456.058, 466.028(1)(m), (o), 466.018 FS. History–New 10-8-85, Formerly 21G-17.02, Amended 10-28-91, Formerly 21G-17.002, Amended 11-22-93, Formerly 61F5-17.002, 59Q-17.002, Amended 11-15-99, 4-22-03, 3-14-13,__________.
In Florida, it is important to be familiar with professional standards and requirements for health care information and records retention. Failure to comply with certain requirements of the law in Florida can result in discipline by one's professional Board. If you have questions about a particular situation involving records requirements or have been the subject of an investigation by the Florida Department of Health or Agency for Health Care Administration regarding recordkeeping issues contact attorney Jeff Howell of the Tallahassee law firm of Howell, Buchan & Strong, Attorneys at Law for a free no obligation consultation at 850-877-7776.