§ 40-15-450 — Patient records; health records.

(A) A dentist shall: (1) maintain timely, legible, accurate, and complete patient records; and (2) timely provide these records to the patient, another dentist, or a designated medical professional in response to a lawful request for the records by the patient or his legal representative or designee. (B) A dental practice must have a procedure for initiating and maintaining a health record for every patient evaluated or treated. For procedures requiring patient consent, there must be an informed consent documented in the patient record. (C) The health record of a patient required under subsection (B) must include appropriate information to: (1) identify the patient, support the diagnosis, and justify the treatment; (2) identify the procedure code or suitable narrative description of the procedure; and (3) document the outcome and required follow-up care. (D) If moderate sedation or deep sedation/general anesthesia is provided, the health record of a patient also must include documentation of: (1) patient weight; (2) type of anesthesia used; (3) type and dosage of drugs administered, if any; (4) fluid administered, if any; (5) a record of vital signs monitoring; (6) patient level of consciousness during the procedure; (7) duration of the procedure; (8) complications related to the procedure or anesthesia, if any; and (9) time-oriented anesthesia record.

Legislative History

HISTORY: 2014 Act No. 222 (S.1036), SECTION 2, eff January 1, 2015.