1. How long do I have to keep a patient’s records?
New York State requires that dentists maintain patient records for a minimum of six (6) years. We have found that many people are under the mistaken belief that it is a seven-year requirement. Moreover, if the patient is a minor (under 18) the requirement is a minimum of six years or until one year after the patient’s 21st birthday, whichever is longer (8 NYCRR § 29.2(a)(3)). It is important to note that these are minimum requirements and many practitioners choose to keep records for longer than is what is required because there is no statute of limitations on OPD complaints.
2. Must I give a patient his/her records, even if the patient owes a balance?
The New York State Public Health Law (and for covered entities HIPAA) requires a dentist to provide access to a patient’s records. Section 18 of the Public Health Law specifically states access to the records shall be provided to a patient within 10 days. Most dentists will actually make copies for the patient in lieu of inspection. The law allows this. The law does allow a dentist to charge a reasonable fee for the copies, but not to exceed the actual cost or seventy-five cents per paper copy. In addition, the law requires the copies to be provided regardless of a patient’s ability to pay or past due balance. It is considered professional misconduct for a dentist to fail to provide such copies pursuant to the Public Health Law.
3. What is included as part of the patient’s record?
The Rules of the Board of Regents provide that it is unprofessional conduct to fail to maintain a record for each patient “which accurately reflects the evaluation and treatment of the patient” (8 NYCRR § 29.2(a)(3)). An inadequate dental history is not only unprofessional conduct, but the source of the greatest cause of problems for a dentist. The dental history and the records that are kept are the dentist’s defense against any complaint by the patient. A complete file should include the dental history, radiographs, study models, drug /laboratory prescriptions, pertinent correspondence (including notes of telephone conversations) and consultation and referral reports. The dental history should include patient’s chief complaint, past dental records, date of last treatment and frequency of past treatments, any complications resulting from past treatments, frequency, type and place of previous radiographs, patient’s view of his/her oral hygiene status and patient’s oral hygiene habits, dentist’s diagnosis, treatment plan or referral information, dentist’s progress notes, and dentist’s termination notes or completion and discharge notes. Any changes that occur over the course of treatment should be recorded and discussed with the patient.
4. What are my recordkeeping obligations when I sell my practice or retire?
The obligation and professional responsibility to retain patient records for the minimum amount of time stated in response number 1 applies to all dentists even if you are retiring or selling your practice. As a professional, when you retire or sell your practice, you must advise your patients. In the event of a sale of the practice, a letter should be sent to patients explaining that the practice is being sold and that unless the patient requests his/her records, the records will in fact be forwarded on to the new practice. In the event of a retirement a similar announcement should be sent advising the patients that they may request that copies of their records be forwarded to a new dentist.