subchapter 16t – patient records

SECTION .0100 – patient records

21 NCAC 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.

History Note:        Authority G.S. 90-28; 90-48;

Eff. October 1, 1996;

Amended Eff. May 1, 2016; July 1, 2015;

Readopted Eff. January 1, 2019.

21 NCAC 16T .0102          TRANSFER OF RECORDS UPON REQUEST

A dentist shall, upon request by the patient of record, provide all information required by the Health Insurance Portability and Accountability Act (HIPAA) and this Rule, including original or diagnostic copies of radiographs and a legible copy of all treatment records to the patient or to a licensed dentist identified by the patient. The dentist may charge a fee not exceeding the actual cost of duplicating the records. The records shall be provided within 30 days of the request and production shall not be contingent upon current, past or future dental treatment or payment of services.

History Note:        Authority G.S. 90-28; 90-48;

Eff. October 1, 1996;

Amended Eff. July 1, 2015; April 1, 2014; November 1, 2008;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 9, 2018.

21 NCAC 16T .0103          INFORMED CONSENT

(a)  To obtain informed consent to a specific procedure or treatment to be provided, the dentist shall discuss with a patient or other person authorized by the patient or by law to give informed consent on behalf of the patient, prior to any treatment or procedure, information sufficient to permit the patient or authorized person to understand:

(1)           the condition to be treated;

(2)           the specific procedures and treatments to be provided;

(3)           the anticipated results of the procedures and treatments to be provided;

(4)           the risks and hazards of the procedures or treatments to be provided that are recognized by dentists engaged in the same field of practice;

(5)           the risks of foregoing the proposed treatments or procedures; and

(6)           alternative procedures or treatment options;

(b)  A dentist is not required to obtain informed consent if:

(1)           treatment is rendered on an emergency basis; and

(2)           the patient is incapacitated.

History Note:        Authority G.S. 90-28; 90-48;

Eff. January 1, 2019.