§59-328.31b. Patient record keeping requirements.
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A. Every dental office or treatment facility, whether individual, group or multi-doctor practice operating under a name, trade name or other professional entity shall maintain written records on each patient treated at the facility and shall make these records available to the Board of Dentistry and other regulatory entities or be subject to the penalties as set forth in Section 328.44a of this title.
B. Each licensed dentist shall maintain written records on each patient that shall contain, at a minimum, the following information about the patient:
1. A current health history listing known illnesses, other treating physicians and current medications prescribed;
2. Results of a clinical examination, including a physical intraoral examination and head and neck examination, tests conducted, and any lab results including the identification, or lack thereof, of any oral pathology or diseases;
3. Treatment plan proposed by the dentist; and
4. Treatment rendered to the patient. The patient record shall clearly identify the dentist and the dental hygienist or dental assistant providing the treatment with the dentist, specialty or dental hygienist license number. The patient record shall include documentation of any medications prescribed, administered or dispensed to the patient.
C. Prior to a dentist prescribing, diagnosing, or overseeing patient treatment for any dental appliance, the patient shall be a patient of record and the dentist shall conduct an in-person patient examination.
D. 1. The name of the dentist or dentists actually providing the dental services to the patient shall appear on all insurance claim forms, billing invoices, or statements sent to the patient and on all receipts if any are given to the patient.
2. Treatment records shall be maintained for each patient that clearly identify the dentist or dentists who performed all dental services for the patient.
E. Whenever patient records are released or transferred, the dentist releasing or transferring the records shall maintain either the original records or copies thereof and a notation shall be made in the retained records indicating to whom the records were released or transferred.
F. All claims being submitted for insurance must be signed, stamped or have an electronic signature by the treating dentist.
G. Patient records may be kept in an electronic data format, provided that the dentist maintains a backup copy of information stored in the data processing system using disk, tape or other electronic back-up system and that backup is updated on a regular basis, at least weekly, to assure that data is not lost due to system failure. Any electronic data system shall be capable of producing a hard copy on demand.
H. All patient records shall be maintained for seven
(7)years from the date of treatment.
I. Each licensed dentist shall retain a copy of each entry in his or her patient appointment book or such other log, calendar, book, file or computer data used in lieu of an appointment book for a period no less than seven
(7)years from the date of each entry thereon.
J. A licensee closing an office shall notify the Board in writing and include the location of where the patient records will be maintained. Added by Laws 2015, c. 229, § 19, eff. July 1, 2015. Amended by Laws 2021, c. 566, § 8, emerg. eff. May 28, 2021; Laws 2024, c. 46, § 6, eff. Nov. 1, 2024; Laws 2025, c. 273, § 13, eff. Nov. 1, 2025.