7.1 Dentist of Record & Minimum Content of the Written Dental Record

The Dentist of Record and the Written Record

Each patient has one dentist of record — s. 466.018(1)

"Each patient shall have a dentist of record. The dentist of record shall remain primarily responsible for all dental treatment on such patient regardless of whether the treatment is rendered by the dentist or by another dentist, dental hygienist, or dental assistant rendering such treatment in conjunction with, at the direction or request of, or under the supervision of such dentist of record."

The operational duties follow:

• The dentist of record shall be identified in the record of the patient.
• If treatment is rendered by another dentist, a hygienist or an assistant, the name or initials of that person shall be placed in the record.
• In any disciplinary proceeding under Chapter 466 or Chapter 456, it is presumed as a matter of law that treatment was rendered by the dentist of record unless otherwise noted in the record.

That presumption is the reason the initialling requirement matters so much. A practice that does not record who performed each service has, by default, attributed everything to the dentist of record.

The statute states its own purpose: "to ensure that the responsibility for each patient is assigned to one dentist in a multidentist practice of any nature and to assign primary responsibility to the dentist for treatment rendered by a dental hygienist or assistant under her or his supervision." Two express limits: the section does not assign responsibility to the dentist of record for treatment rendered under a proper referral to another dentist not in practice with the dentist of record, and it does not prohibit a patient from voluntarily selecting a new dentist without the permission of the dentist of record.

Presumptions and changes of dentist of record — s. 466.018(2)

• If the dentist of record is not identified in the record, it is presumed as a matter of law that the dentist of record is the owner of the dental practice in which the patient was treated.
• In a multidentist practice the dentist of record shall not change unless the subsequent treating dentist acknowledges in writing in the record that he or she is now the dentist of record.
• On such a change it is presumed as a matter of law that the new dentist of record has taken or reviewed the medical history and dental records, has examined the patient, and has either developed a new treatment plan or agreed to continue the preexisting one.
• The dentist of record shall be changed when the dentist of record leaves the practice where treatment was being rendered and the patient elects to continue treatment in the office where treatment began.

Rule 64B5-17.002(6) adds the tie-breaker hierarchy: the dentist of record is the one identified in the record; or who provides a specific treatment and is noted as dentist of record for it; or, where there has been more than one provider, the dentist who places the final restoration, does the surgical procedure, makes the diagnosis, or finishes the service or procedure in question; or, if still unidentifiable, the owner of the dental practice.

Minimum record content — s. 466.018(3) and Rule 64B5-17.002(1)

The statute requires every dentist to maintain written dental records and medical history records which justify the course of treatment, including patient history, examination results, test results, and X rays if taken.

The rule requires records kept legibly and with sufficient detail to clearly demonstrate why the course of treatment was undertaken, containing at a minimum: patient histories; X-rays if taken; examination results; test results; records of drugs prescribed, dispensed, or administered; reports of consultation or referrals; and copies of records, reports or other documentation obtained from health care practitioners at the dentist's request and relied upon in determining appropriate treatment.

Amending a record — Rule 64B5-17.002(2)

This is the most frequently examined records rule in Florida, because it prescribes a method rather than a principle:

• Any addition, correction, modification, annotation or alteration must be clearly noted as such;
• It must include the date the change was made;
• It must be initialled by the person making the change;
• It must have an explanation for the change;
• An original entry cannot be partially or wholly removed — to represent a deletion, the entry must be struck through where it will remain legible; and
• A change made on the same date as the original entry must also include the time of the change.

Transfer or release — Rule 64B5-17.002(3)

Whenever records are released or transferred, the releasing dentist shall maintain either the original records or copies, and a notation shall be made in the retained records indicating to whom the records were released and the authority for the release. Transfers within a multidentist practice must be done and documented in strict accordance with s. 466.018, F.S.

Multidentist practices — s. 466.018(4)

The owner dentist must maintain either the original or a duplicate of all patient records — charts, histories, examination and test results, study models and X rays — of any patient treated by any dentist at the owner's facility, whether or not the owner was involved in that treatment. This does not relieve the dentist of record of their own duty.

An owner may be relieved of that duty only by transferring custody at the request of the patient or the patient's legal representative and retaining, in lieu of the records, a written statement signed by the owner dentist, the person who received the records, and two witnesses, listing the date, the records transferred, and the persons to whom they were transferred. A departing dentist of record may be similarly relieved by transferring custody to the practice owner and retaining an equivalent statement signed by the dentist of record, the owner, and two witnesses. The owner dentist shall provide reasonable access to duplicate records at cost.

Rule 64B5-17.002(7) makes records the property of the owner dentist of the practice, who is ultimately responsible for all record-keeping requirements, responsible for records of patients seen by any employee, associate or visiting dentist, with multiple owners severally and equally responsible. A lessor or owner dentist is not responsible for the records of an independent dentist merely leasing space or staff services to operate a separate practice within the facility.

Appointment books — Rule 64B5-17.002(5)

Each dentist must retain a copy of each entry in the patient appointment book — or such other log, calendar, book, file or computer data used in lieu of one — for no less than four (4) years from the date of each entry. The appointment book is a distinct retention obligation from the clinical record.

Electronic records — Rule 64B5-17.002(8)

Records may be electronic provided the dentist maintains a back-up copy using disk, tape or other secure electronic back-up system, on-site or off-site, updated in a time frame that does not exceed seventy-two hours (72 hrs.), to ensure data is not lost through system failure. Any electronic system must be capable of producing a hard copy on lawful demand in accordance with federal or state laws and rules.