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.
21 NCAC 16T. 0104 NOTICE AND TRANSFER OF RECORDS UPON CEASING PRACTICE
(a) Patient Notification Upon Closure of Practice. A dentist who is a sole practitioner and closes a dental practice for reasons other than disciplinary action by the Board shall notify all patients with a pending treatment plan or a scheduled appointment of the closure and consult with the patients on options for continued care and transferring of the patient record to another provider or returning it to the patient. Nothing in this Rule shall alter the dentist's obligations under Rule .0101 of this Section to retain the patient record unless it is either transferred to another provider or returned to the patient. A dentist shall document the transfer or return of each patient record.
(b) Patient Notification Upon Revocation or Active Suspension of License. Unless an Order of the Board specifies otherwise, a dentist whose license is actively suspended for a period of 30 days or longer or is revoked by Order of the Board shall notify all patients with a pending treatment plan or a scheduled appointment of the suspension or revocation in not more than 10 days after the effective date of the active suspension or revocation, the reasons for the suspension or revocation, and consequent inability of the licensee to continue treatment after the effective date of suspension or revocation. The dentist shall advise such patients that the patients may seek treatment from another licensed provider if further treatment is required during the period of active suspension or after the revocation. The dentist shall document the notice in the patient record.
(c) Transfer of Patient Records Upon Revocation or Active Suspension of License– A dentist shall not abandon patient records. Unless otherwise specified by Board Order, within 30 days after the effective date of an active suspension or revocation of a license, the dentist shall deliver all patient records in his or her possession for each patient with an ongoing treatment plan or a scheduled appointment either to the patient or to another treatment provider as directed by the patient, or document good faith efforts to do so. A dentist shall not transfer patient records containing confidential information to another treatment provider in a different practice without prior consent from the patient. The dentist shall document the consent to transfer in the patient record and the transfer or return of each patient record.
(d) Transfer of Patient Records to Trustee. If the Board determines that patient records have been abandoned by a dentist, including upon the suspension or revocation of a license or the death or disability of a sole practitioner, the Board may seek a judicial order appointing a licensed dentist to act as trustee of the abandoned patient records. The trustee shall take steps to contact each patient for return or transfer of the patient record. The trustee shall not transfer patient records containing confidential information to another treatment provider without prior consent from the patient, documented in the record. Upon the death of a dentist who is not a sole practitioner, a dentist who is an owner or employed in the same practice as the deceased dentist shall take custody of the deceased dentist's patient records and notify the patients to arrange for continued care either within the practice or by transferring the patient record to another dentist.
(e) Proof of Compliance. A licensee whose license is actively suspended or revoked by Order of the Board shall keep and maintain records of the steps taken under subjections (b) and (c) of this Rule so that, upon any subsequent proceeding, proof of compliance with this Rule and any Order of the Board shall be available for the Board to review. Proof of compliance with subsections (b) and (c) shall be a prerequisite to consideration of any petition for reinstatement or stay of active suspension. If a trustee was appointed for custody of the licensee's patient records in accordance with subsection (d) of this Rule, the petitioner must demonstrate to the Board, as prerequisites to consideration for any petition for reinstatement or stay of active suspension, that the abandonment of the patient records was caused by an impairment, disability or other condition outside of petitioner's control and that the petitioner has paid the trustee or Board for documented expenses incurred in connection with the custody of the abandoned patient records, even when cause is demonstrated.
History Note: Authority G.S. 90-28; 90-41; 90-48; 90-48.1;
Eff. June 1, 2025.