21 NCAC 16T .0101. RECORD CONTENT

(a)  A dentist shall maintain complete treatment records on all patients treated for a period of at least 10 years.  Treatment records may include such information as the dentist deems appropriate but must include:

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

(2)           Patient's nearest relative or responsible party;

(3)           Current health history;

(4)           Diagnosis of condition;

(5)           Specific treatment rendered and by whom; and

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

(b)  Records may also include the following:

(1)           Treatment plans;

(2)           Radiographs, study models and other diagnostic aids; and

(3)           Patient's financial records and copies of all insurance claim forms.

 

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

Eff. October 1, 1996.