Yes. Protecting your health and your smile 175 Bloor St. E., North Tower, Suite 601, Toronto, ON M4W 3R8 t 416-961-6234 tf 1-800-268-2346 f 416-961-6028 In the case of a minor, these records must be kept for at least ten years from the date the patient turned 18 years of age. Stored records should be kept in a systematic fashion for easy retrieval. Dentists must protect the patient’s personal health information and should review the company’s privacy policy. A drug register must record and account for all narcotics, controlled drugs, benzodiazepines and targeted substances that are kept on-site at the dental office. Dentists are legally required to keep dental records. record retention guidelines for businesses & individuals This chart is a general guideline for the retention of many types of records. Yes, the patient can pick up copies of their dental records from your office or request that they be forwarded by registered mail or courier to their home. records, electronic records, retention of records, and compliance with rapidly changing state and federal re-quirements for record keeping. College regulations must be followed, regardless of a financial dispute between a patient and a dentist. While a patient may request copies of the dental records for a spouse or a child 16 and over, the dentist will require the consent of these individuals to release their records. In such cases, the original dental records should be sent directly from dentist to dentist by courier and, after consultation and treatment, the original dental records should be returned to the dentist who lent them. Drug Register Dentists must maintain a drug register to record and account for all narcotics, controlled drugs and targeted substances that are kept on-site. It may be helpful for dentists to retain a copy of documentation attesting to that person’s signed consent to the release of information to the patient’s family in the patient’s record. If there is any doubt about what the patient has consented for you to release, contact the patient or the new dentist for clarification. Yes. There is increasing pressure on all health care professionals to convert from paper records to electronic records. Each entry should be initialled or attributable to the person who made the entry. part 293 of title 5, Code of Federal Regulations. Whether this is possible may depend on the number and type of dental records requested and whether the services of an outside duplication facility (for dental radiographs and study models) are required. Digital images can be provided on removable media or by secure e-mail with strong encryption. What do I have to do? After drafting a proposed revision, COPPS sought feedback and incorporated suggestions from the APA Eth- Among other things, the Guidelines state that patient records must be accurate, comprehensive, legible and accessible. Can I give my patients their original dental radiographs or study models? Alternatively, the device may be physically destroyed. Records for which the most recent entry was created on or after June 1, 2013 must be kept for 16 years from the date of last entry. Dental Recordkeeping Online Course. eRuling Requirements. Recall History Name: MR. / MISS / MRS. / MS. / DR. The following are the record keeping requirements, all of which fall into the high risk (HR) category: o A log of test results during sterilization is maintained and reviewed. Once the retention period has passed, how can electronic patient records be disposed in a manner that maintains confidentiality. I have just received a request for copies of dental records from a denturist/independent dental hygienist. 3. No. Dentists are legally required to keep dental records. Only a dentist can be a custodian of patients’ dental records. However, the privacy legislation requires that patients’ dental records be stored in secure premises to prevent unauthorized access and dentists should take reasonable steps to protect them from theft and damage from fire or flood. The request for dental records does not have to originate from another dental office, and dentists can provide copies of dental records to their patients directly if requested. Border Patrol History. During the course of a missing person or criminal investigation, the Ontario Provincial Police may legally require a dentist to surrender dental records to them by producing a search warrant issued by a judge or a justice of the peace. Do I have to release them? Can a patient request copies of the dental records for his/her spouse and/or children? They must be permanently deleted or irreversibly erased, including any back-up or other copies. There was a flood/fire in my dental office and some of my patients’ dental records were damaged or destroyed. Can dentists store archived records off-site? 3.7 . When a dental office is transitioning from paper records to electronic records, can existing paper records be scanned and destroyed? Confidentiality requirements apply to paper, digital, and other forms of patient information and dental records.Records should be stored securely, not left unattended or in public areas of the office, and destroyed appropriately and securely at the end of the required retention period (See Section VII). Chart records and other documents must be properly destroyed either by shredding or incineration. The release and transfer of dental records should be accomplished within one to two weeks of receipt of the request. All Rights Reserved. Can I withhold the release of dental records because a patient did not settle his/her account? Dentists should avoid using e-mail to communicate the personal health information of patients, unless they are employing a secure e-mail service with strong encryption. In most cases the patient’s new dentist will have provided a request for records signed by the patient. RCDSO, Standard of Practice Infection Prevention and Control in the Dental Office (2018) CDHO Infection Prevention and Control (IPAC) Guidelines (2018) M . You may also provide the College with a report of the incident and the list of patients whose records were stolen. Keep the register in a secure area in the office, preferably with the drugs. (2) Records management requirements will be integrated into DoD Component In most cases, notification is required. Strategic Plan. Notify police of the theft and report the breach to the Office of the Information and Privacy Commissioner of Ontario. Anatomy of a Good Dental Record To assist members in creating and maintaining good records, RCDSO published revised Guidelines on Dental Recordkeepingin November 2019. This may include mailing costs, charges from a dental laboratory or radiograph duplicating facility, and materials costs. Clinical and financial patient records, as well as radiographs, consultant reports, and drug and lab prescriptions must be maintained for at least ten years after the date of the last entry in the patient’s record. Toll Free: 800.565.4591 www.rcdso.org. If stored off-site, patient consent must be obtained. What would be considered a reasonable time frame for the release of dental records? It is unacceptable to withhold the transfer of records because of an outstanding account balance. Can I provide copies of dental records to my patient’s new dentist? Clinical and financial patient records, as well as radiographs, consultant reports, and drug and lab prescriptions must be maintained for at least ten years after the date of the last entry in the patient’s record. Personnel recordkeeping regulations are found in . In the case of a minor, these records must be kept for at least ten years after the day the patient turned 18. The IPC/ON has a breach notification assessment tool that guides dentists in evaluating whether they have a legal obligation to notify about the loss of their personal health information. In most cases (unless otherwise agreed to in writing), principal dentists retain the patients’ original dental records and must provide copies of the records to former associates as requested and consented to by the patients. In most cases, a parent can request and obtain copies of the dental records for children who are under the age of 16 years. Let’s Review the new RCDSO Guidelines Tuesday April 9th 2019 6:30-9PM-SOLD OUT Wednesday April 17th 2019 6:30-9PM-NEW DATE ADDED SOLD OUT Tues… Resource: Regulation . Under Ontario’s Personal Health Information Protection Act (PHIPA), the authorized person is the deceased’s estate trustee or the person who has assumed responsibility for the administration of the deceased’s estate. The College also publishes the Medical History Recordkeeping Guide, which includes additional supporting materials for this key area of … Finally, other APA prac-tice guidelines were examined to ensure internal consis-tency of APA policies. There is a regular schedule for environmental cleaning in the designated reprocessing area that includes a written policy and procedure and clearly defined responsibilities. Records of Selling a House (Documentation for Capital Gains Tax) Records of Selling a Stock (Documentation for Capital Gains Tax) Receipts, Cancelled Checks and other Documents that Support Income or a Deduction on your Tax Return (Keep 3 years from the date the return was filed or 2 years from the date the tax was paid -- which ever is later) You may wish to notify the College, too. Patients are entitled to copies of any or all of their dental records. Good record keeping is an important aspect for health and social care professionals. What financial records must be retained for patients? Preclearance. Keep accurate logs of all BI results in accordance with RCDSO record keeping requirements. If the system cannot be restored from a backup copy, it may be possible to recover data from a damaged hard drive. These financial records must be retained for at least ten years from the date of the last entry in that record. Customs Bulletin and Decisions. This information should be collected systematically, recording the patient’s present state of health and any serious illnesses, conditions or adverse reactions in the past that might affect the dental management of a patient. The patient can indicate this in advance with their signed consent. Are there any circumstances where original dental records can be released? Health information custodians may also disclose personal health information to police without a warrant in limited circumstances outlined in PHIPA. Can I charge the patient for the release of dental records? You should retain these records according to the following guidelines: Car records (keep until car sold) Credit card receipts (keep until reconciled on your credit card statement) ATM and deposit slips (keep until reconciled on your bank statement) In keeping and maintaining acceptable patient records, the following principles are essential: • All entries sh ould be dated and recorded by hand in permanent ink or typewritten, or be in an acceptable electronic format and “locked” on the date to which they are attributed. Dentists do not have to notify patients if their records are stored in the basement of the dental office or other premises that are controlled by the dentist. The College also produced the Medical History Recordkeeping Guide, which includes additional supporting materials for this key area of dental practice, including: © Copyright 2021 Royal College of Dental Surgeons of Ontario. The New Zealand Standard Health Records (NZS 8153:2002) sets out the minimum requirements for the appropriate documentation and management of health records within public and private You should notify (verbally or in writing) patients currently in treatment and other active patients about what has occurred and whether any records may need to be recreated. Financial records should be kept for the same retention period described above. The province of Ontario has committed to implementing a comprehensive electronic health record for all Ontarians, and similar efforts are being made in other provinces and nations. control and record keeping. Are patients entitled to copies of their dental records? The Guidelines of the Royal College of Dental Surgeons of Ontario contain practice parameters and standards which Please review your previous medical history (dated / / ) and advise your dentist if there That dentist should document the patient’s consent for this, as well as their subsequent return. Patients are entitled to diagnostic quality duplicate radiographs on film, photographic paper or appropriate digital formats. The first step is to determine which records can be retrieved or salvaged. Cargo Security. ledgers to keep records for their patients. The RCDSO has recently released new guidelines for dental offices to follow. Legal Support for Victims of Sexual Abuse, List of Illegal/Unauthorized Practitioners, Sedation and/or General Anesthesia Inspection Program, COVID-19: Managing Infection Risks During In-Person Care, COVID-19 - Guidance for the Use of Teledentistry, Professional Patient-Dentist Relationships, Personal Health Information Protection Act, Practice Name Registration Application Form, Principles for Approved Sponsors and Core Course Presenters, Information on Change of Practice Ownership and Retiring, Information on New Practice Setup and Changing Practice Locations, Information on Prescribing and Dispensing Drugs, Post-Specialty Training Licence/Certificate, Registration Requirements for Int'l Applicants, Finance, Property and Administration Committee, Inquiries, Complaints and Reports Committee. An electronic copy of claim forms on a properly backed-up system is acceptable. However, dentists can decide whether and how long to retain copies of other correspondence with insurance companies about dental insurance claims. What happens if the request for patient records comes from the police? Canaray's standards of practice aim to meet or exceed all standards of practice set forth by the Royal College of Dental Surgeons of Ontario. The estate trustee or the person who has assumed responsibility for the administration of the deceased dentist’s estate assumes responsibility for retaining the dental records until they can be transferred to another dentist. However, the use of electronic records by dentists, including digital radiography, has grown substan - tially in Ontario, and the sophistication of hardware and software has evolved significantly since the Guidelines on Dental Recordkeeping were … (10 years) Chemical Indicators (Class 5 Strips) A Class 5 is an indicator known as an 'Integrator' designed to react to all critical sterilization parameters (temp, pressure, time) The Royal College of Dental Surgeons of Ontario (RCDSO) publishes Guidelines on Dental Recordkeeping, which includes a sample medical history questionnaire. This interactive online course will discuss strategies to help improve recordkeeping and patient care in your dental office. Yes, if the patient has consented to the release of the records. Informed Compliance Publications. There are companies that specialize in recovery and reconstruction of paper records and data recovery of electronic records. • All … Record Keeping Documentation of the sterilization of dental instruments and devices is a critical element of a dental practice’s IPAC program. Can a dentist e-mail a patient’s radiographs and other records to the patient or to another dentist? It is not considered appropriate to charge an administrative fee for the dental staff ’s time. SEDATION, INFECTION CONTROL, AND RECORD KEEPING. Federal Register Notices. The financial record must include a copy of any written agreement with the patient and provide an accurate statement of the patient’s account, including the date and amount of all fees charged, commercial laboratory fees, payments received (including the method of payments) and any adjustments to the account. The requests made by patients and the release of dental records should be documented in the patients’ records. In addition, record this information in the patient’s clinical records along with any instructions given. Approved by Council – May 2013 This is replacing the document last published in August 2002. Educational Requirements & Professional Responsibilities for Implant Dentistry. GUIDELINES. What should I do? An accurate written record detailing all aspects of patient monitoring is important because it contributes to the circulation of information amongst the different teams involved in the patient's treatment or care. © Copyright 2021 Royal College of Dental Surgeons of Ontario. Dental Recordkeeping Guidelines April 2013 Contents 2 Introduction 4 Medical and Dental History 5 Confidentiality 6 Dental Examination 8 Informed Consent 9 reatment T Records 10 Electronic Recordkeeping 11 Financial Records 12 Drug Records 13 Ownership, Retention, Transfer and Disposition of Dental Records Practice Guidelines of the College of Dental Surgeons of BC (CDSBC) should Diagnostic or study models are considered part of the patient’s record and must be kept for the same retention period prescribed by the regulations. Border Security. The dentist needs to determine who is legally authorized to consent to the release of the patient’s personal health information. A decision to keep working models should be based on the complexity of the case and is left to the judgement of the individual practitioner. 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