Patient records.

20-02-01-09. Patient records. 1. A dentist shall maintain a patient's dental records in a manner consistent with the protection of the welfare of the patient. 2. Dentists shall release patient dental records within a reasonable time of request. Failure to do so may result in violations of North Dakota Century Code chapter 43-28 and section 23-12-14. 22 3. A dentist who fails to release dental records within ten days of receipt of the request shall provide a written statement to the patient or authorized requestor detailing the cause of delay and an estimation of when records will be produced. Failure to provide the written statement may result in violations of subsection 23 of North Dakota Century Code section 43-28-18. 4. The dentist may charge a nominal fee for duplication of records as provided by North Dakota Century Code section 23-12-14, but may not refuse to transfer records for nonpayment of any fees. 5. Dental records must be legible and include a chronology of the patient's progress throughout the course of all treatment and postoperative visits. All entries in the patient record must be dated, initialed, and handwritten in ink or computer printed. Digital radiographs must be transferred by compact or optical disc, electronic communication, or printing on high quality photographic paper. All transferred film or digital radiographs must reveal images of diagnostic quality using proper exposure settings and processing procedures. 6. "Billing information" as set forth in North Dakota Century Code section 43-28-18 means records providing complete and accurate explanations of all dollar amounts assessed to the patient, the date the amount was assessed to the patient, and the date the assessed service was provided to the patient. 7. "Dental record" or "patient's chart" means the detailed history of the physical examination, diagnosis, treatment, patient-related communications, and management of a patient documented in chronological order. The dental records include any document, charting, study models, doctor's notations, billing information, insurance document, or combination of documents that pertains to a patient's medical history, diagnosis, prognosis, or medical condition, which is generated and maintained in the process of the patient's dental health care treatment, and any other materials as set forth in subsection 23 of North Dakota Century Code section 43-28-18, and the following components: a. Personal data to include name, address, date of birth, name of patient's parent or guardian, name and telephone number of a person to contact in case of an emergency, and patient's insurance information. b. Patient's reason for visit or chief complaint. c. Dental and physical health history. d. Clinical examination must include record of existing oral health status, radiographs used, and any other diagnostic aids used. e. Diagnosis. f. Dated treatment plan except for routine dental care, such as preventive services. g. Informed consent, which must include notation of treatment options discussed with the patient, including prognosis of the treatment plan, benefits and risks of each treatment, and documentation of the treatment the patient has chosen. h. Corrections of records, which must be legible, unless electronic and written in ink, and contain no erasures or use of "white-outs". If incorrect information is placed in the record, it must be crossed out with one single line and initialed by the dental health care worker. i. Progress notes, which must include a chronology of the patient's progress throughout the course of all treatment and postoperative visits of treatment provided; medications used and materials placed; the treatment provider by name or initials; name of collaborating 23 dentist; administration information of nitrous oxide inhalation or any medication dispensed before, during, or after discharge, and patient status at discharge. 8. Each patient shall have access to health provider information as it pertains to their treating doctor or potential doctors. Any entity utilizing telehealth shall provide upon request of a patient the name of the dentist, telephone number, practice address, and state license number of any dentist who was involved with the provision of services to a patient before or during the rendering of dental services. 9. "Patient", for the purposes of this section, means an individual who has received dental care services from a provider for treatment of a dental condition. 10. "Retention of records" means a dentist shall retain a patient's dental record for a minimum of six years after the patient's last examination, prescription, or treatment. Records for minors must be retained for a minimum of either one year after the patient reaches the age of eighteen or six years after the patient's last examination, prescription, or treatment, whichever is longer. Proper safeguards must be maintained to ensure safety of records from destructive elements. The requirements of this rule apply to electronic records as well as to records kept by any other means or maintained by a permissible ownership entity as identified by North Dakota Century Code section 43-28-25. History: Effective April 1, 2006; amended effective January 1, 2011; July 1, 2022; April 1, 2026. General Authority: NDCC 43-28-06 Law Implemented: NDCC 43-28-06, 43-28-18