How long to keep it, and who can have access
The dental record, or patient’s chart, is the official office document that records the treatment done in the dental office.
The dental record also serves to provide continuity of care for the patient and is critical in the event of a malpractice insurance claim. State and federal laws determine how the dental record is handled, how long it is kept, and who may have access to the information.
The information in the dental record should primarily be clinical in nature.
The following are examples of what is typically included in the dental record:
- database information, such as name, birth date, address, and contact information
- place of employment and telephone numbers (home, work, mobile)
- medical and dental histories, notes and updates
- progress and treatment notes
- conversations about the nature of any proposed treatment, the potential benefits and risks associated with that treatment, any alternatives to the treatment proposed, and the potential risks and benefits of alternative treatment, including no treatment, etc.
The dental record is an extremely useful document. Proper maintenance and security of the information located therein is vital. Review the Dental Records publication below for helpful information regarding records management and additional helpful resources and references.
Disclaimer: These materials are intended to provide helpful information to dentists and dental team members. They are in no way a substitute for actual professional advice based upon your unique facts and circumstances. This content is not intended or offered, nor should it be taken, as legal or other professional advice. You should always consult with your own professional advisors (e.g. attorney, accountant, insurance carrier). To the extent ADA has included links to any third party web site(s), ADA intends no endorsement of their content and implies no affiliation with the organizations that provide their content. Further, ADA makes no representations or warranties about the information provided on those sites.