Good dental recordkeeping is critical to the practice of dentistry. It ensures continuity of care for patients and may help to reduce the likelihood of a complaint. The Dental Recordkeeping Guidelines contain the requirements for dental recordkeeping and the ownership, transfer and retention of dental records.
Dental Recordkeeping Guidelines
Patient RegistrationMedical History Dental HistoryDiagnosis and Treatment PlanTreatment Notes
Initial Periodontal Occlusal ExaminationPeriodontal ChartOdontogram Existing and Planned TreatmentLesion Tracking Sheet
Dentists must now maintain complete patient records as follows:
addition to clinical records, other records that must be retained
include appointment records, lab prescriptions and invoices. Diagnostic
or study models are also considered part of the permanent patient record
and must be kept for the prescribed period. Working models do
not have to be retained for any specific period of time. A decision to
keep working models should be based on the complexity of the case and is
left to the judgment of the individual practitioner.
Exceptions: The above guidelines do not apply to minors and person under a disability. In these cases, the limitation periods do not begin running until the person turns 19 or until the disability ends.