WSR 14-04-022 PROPOSED RULES DEPARTMENT OF HEALTH (Dental Quality Assurance Commission) [Filed January 27, 2014, 8:37 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 09-13-097.
Title of Rule and Other Identifying Information: WAC 246-817-305 Record content and 246-817-310 Record retention and accessibility requirements, creating a new rule and amending an existing rule to provide dental treatment record content and retention requirements.
Hearing Location(s): Department of Health, 310 Israel Road S.E., Room 152/153, Tumwater, WA 98501, on April 18, 2014, at 8:00 a.m.
Date of Intended Adoption: April 18, 2014.
Submit Written Comments to: Jennifer Santiago, P.O. Box 47852, Olympia, WA 98504-7852, e-mail http://www3.doh.wa.gov/policyreview/, fax (360) 236-2901, by April 11, 2014.
Assistance for Persons with Disabilities: Contact Jennifer Santiago by April 11, 2014, TTY (800) 833-6388 or 711.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rules modify WAC 246-817-310 and creates new WAC 246-817-305. The proposed rules provide detailed requirements for content that must be included in a patient record. The proposed rules also remove unnecessary and outdated language.
Reasons Supporting Proposal: The proposed rules clarify what should be included in a patient record. The proposed rules also ensure that patient records are complete, legible, and consistent. A complete and accurate patient record is vital for patient safety and for appropriate regulation. Thorough records are necessary to inform the work of other treatment providers who subsequently treat the patient, as well as for the commission when investigating complaints and regulating practitioners.
Statutory Authority for Adoption: RCW 18.32.655 and 18.32.0365.
Statute Being Implemented: RCW 18.32.655 and 18.32.0365.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Washington state dental quality assurance commission, governmental.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Jennifer Santiago, 310 Israel Road S.E., Tumwater, WA 98501, (360) 236-4893.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rule would not impose more than minor costs on businesses in an industry.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Jennifer Santiago, P.O. Box 47852, Olympia, WA 98504-7852, phone (360) 236-4893, fax (360) 236-2901, e-mail jennifer.santiago@doh.wa.gov.
January 24, 2014
LouAnn Mercier, D.D.S.
Chair
NEW SECTION
WAC 246-817-305 Record content.
(1) A licensed dentist who treats patients shall maintain legible, complete, and accurate patient records.
(2) The patient record must reflect diagnosis and treatment performed and contain financial records.
(3) The patient record must include at least the following information:
(a) For each record entry, the signature or electronic verification of the responsible dentist or dental hygienist;
(b) The date of each patient record entry, document, radiograph or model;
(c) An up-to-date treatment plan;
(d) The physical examination findings documented by subjective complaints, objective findings, and an assessment or diagnosis of the patient's condition;
(e) Up-to-date dental and medical history that may affect dental treatment;
(f) Any diagnostic aid used including, but not limited to, images, radiographs, and test results. Retention of molds or study models except for orthodontia or full mouth reconstruction is at the discretion of the practitioner;
(g) A complete description of all treatment/procedures administered at each visit;
(h) An accurate record of any medication(s) administered, prescribed or dispensed including:
(i) The date prescribed or the date dispensed;
(ii) The name of the patient prescribed or dispensed to;
(iii) The name of the medication; and
(iv) The dosage and amount of the medication prescribed or dispensed, including refills;
(i) Referrals and any communication to and from any health care provider;
(j) Notation of communication to or from the patient or patient's parent or guardian, including:
(i) Discussion of potential risk(s) and benefit(s) of proposed treatment, recommended tests, and alternatives to treatment, including no treatment or tests;
(ii) Posttreatment instructions;
(iii) Patient complaints and resolutions; and
(iv) Termination of doctor-patient relationship; and
(k) A copy of each laboratory referral retained for three years as required in RCW 18.32.655.
(4) Complete manual treatment entries must not be erased or deleted from the record.
(a) Mistaken manual entries must be corrected with a single line drawn through the incorrect information. New or corrected information must be initialed and dated.
(b) Complete electronic treatment entries must include deletions, edits, and corrections.
AMENDATORY SECTION (Amending WSR 95-21-041, filed 10/10/95, effective 11/10/95)
WAC 246-817-310 ((Maintenance and)) Record retention ((of records)) and accessibility requirements.
((Any dentist who treats patients in the state of Washington shall maintain complete treatment records regarding patients treated. These records shall include, but shall not be limited to X rays, treatment plans, patient charts, patient histories, correspondence, financial data and billing. These records shall be retained by the dentist for five years in an orderly, accessible file and shall be readily available for inspection by the DQAC or its authorized representative: X rays or copies of records may be forwarded to a second party upon the patient's or authorized agent's written request. Also, office records shall state the date on which the records were released, method forwarded and to whom, and the reason for the release. A reasonable fee may be charged the patient to cover mailing and clerical costs.
Every dentist who operates a dental office in the state of Washington must maintain a comprehensive written and dated record of all services rendered to his/her patients. In offices where more than one dentist is performing the services the records must specify the dentist who performed the services. Whenever requested to do so, by the secretary or his/her authorized representative, the dentist shall supply documentary proof:
(1) That he/she is the owner or purchaser of the dental equipment and/or the office he occupies.
(2) That he/she is the lessee of the office and/or dental equipment.
(3) That he/she is, or is not, associated with other persons in the practice of dentistry, including prosthetic dentistry, and who, if any, the associates are.
(4) That he/she operates his office during specific hours per day and days per week, stipulating such hours and days.)) (1) A licensed dentist who treats patients eighteen years and older shall keep readily accessible patient records for at least six years from the date of the last treatment.
(2) A licensed dentist who treats patients under the age of eighteen years old shall keep readily accessible patient records for at least six years after the patient reaches eighteen years old.
(3) A licensed dentist shall respond to a written request to examine or copy a patient's record within fifteen working days after receipt. A licensed dentist shall comply with chapter 70.02 RCW for all patient record requests.
(4) A licensed dentist shall comply with chapter 70.02 RCW and the Health Insurance Portability and Accountability Act, 45 C.F.R. destruction and privacy regulations.
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