I would again like to stress the importance of maintaining detailed patient dental records in your practice. Failure to maintain adequate patient records is a violation commonly cited in many of our disciplinary cases. The standard is to keep written dental records and medical history records justifying the course of treatment of the patient including, but not limited to: patient histories, clinical examination results, results of tests conducted, radiographs used for diagnosis and treatment planning, and notes concerning treatment rendered to the patient. If a patient is referred to a specialist, it should be noted in the record.
When reviewing disciplinary cases, the Probable Cause Panel determines whether these items were sufficiently detailed in the patient’s record. The law requires that you maintain these records for four years following the patient’s last appointment. Our goal is to ensure that every dentist meets these minimum standards of practice.
Wade Winker, DDS