WSR 16-07-084 PERMANENT RULES DEPARTMENT OF HEALTH (Dental Quality Assurance Commission) [Filed March 17, 2016, 2:52 p.m., effective April 17, 2016] Effective Date of Rule: Thirty-one days after filing.
Purpose: Amending WAC 246-817-310 Maintenance and retention of records and new WAC 246-817-304, 246-817-305, and 246-817-315 for dental treatment record content, retention, accessibility, and business record accessibility. The rules move business record requirements and more thoroughly detail the information that must be included in patient records. It also extends the length of time patient records must be retained, from five years to six years for all patients.
Citation of Existing Rules Affected by this Order: Amending WAC 246-817-310.
Other Authority: RCW 18.32.002.
Adopted under notice filed as WSR 15-24-118 on December 1, 2015.
Changes Other than Editing from Proposed to Adopted Version: WAC 246-817-304, editing changes; WAC 246-817-305, editing changes and deletion of the word "treatment" in subsection (4); WAC 246-817-310, added "from a patient" in subsection (2); and WAC 246-817-315, changed first sentence to read "If requested as part of an investigation authorized by the secretary" and changed "relating" to "governing" in subsection (2).
A final cost-benefit analysis is available by contacting Jennifer Santiago, P.O. Box 47852, Olympia, WA 98504, phone (360) 236-4893, fax (360) 236-2901, e-mail jennifer.santiago@doh.wa.gov.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 3, Amended 1, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 3, Amended 1, Repealed 0.
Date Adopted: January 22, 2016.
Charles Hall, DDS, Chair
Dental Quality Assurance Commission
NEW SECTION
WAC 246-817-304 Definitions.
The following definitions apply to WAC 246-817-304 through 246-817-315 unless the context requires otherwise:
(1) "Clinical record" is the portion of the record that contains information regarding the patient exam, diagnosis, treatment discussion, treatment performed, patient progress, progress notes, referrals, studies, tests, imaging of any type and any other information related to the diagnosis or treatment of the patient.
(2) "Financial record" is the portion of the record that contains information regarding the financial aspects of a patient's treatment including, but not limited to, billing, treatment plan costs, payment agreements, payments, insurance information or payment discussions held with a patient, insurance company or person responsible for account payments.
(3) "Notation" is a condensed or summarized written record/note.
(4) "Patient record" is the entire record of the patient maintained by a practitioner that includes all information related to the patient.
NEW SECTION
WAC 246-817-305 Patient record content.
(1) A licensed dentist who treats patients shall maintain legible, complete, and accurate patient records.
(2) The patient record must contain the clinical records and the financial records.
(3) The clinical record must include at least the following information:
(a) For each clinical record entry note, the signature, initials, or electronic verification of the individual making the entry note;
(b) For each clinical record entry note, identify who provided treatment if treatment was provided;
(c) The date of each patient record entry, document, radiograph or model;
(d) The physical examination findings documented by subjective complaints, objective findings, an assessment or diagnosis of the patient's condition, and plan;
(e) A treatment plan based on the assessment or diagnosis of the patient's condition;
(f) Up-to-date dental and medical history that may affect dental treatment;
(g) Any diagnostic aid used including, but not limited to, images, radiographs, and test results. Retention of molds or study models is at the discretion of the practitioner, except for molds or study models for orthodontia or full mouth reconstruction which shall be retained as listed in WAC 246-817-310;
(h) A complete description of all treatment/procedures administered at each visit;
(i) 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.
(j) Referrals and any communication to and from any health care provider;
(k) Notation of communication to or from the patient or patient's parent or guardian, including:
(i) Notation of the informed consent discussion. This is a discussion of potential risk(s) and benefit(s) of proposed treatment, recommended tests, and alternatives to treatment, including no treatment or tests;
(ii) Notation of posttreatment instructions or reference to an instruction pamphlet given to the patient;
(iii) Notation regarding patient complaints or concerns associated with treatment, this includes complaints or concerns obtained in person, by phone call, e-mail, mail, or text; and
(iv) Termination of doctor-patient relationship; and
(l) A copy of each laboratory referral retained for three years as required in RCW 18.32.655.
(4) Clinical record entries must not be erased or deleted from the record.
(a) Mistaken handwritten entries must be corrected with a single line drawn through the incorrect information. New or corrected information must be initialed and dated.
(b) If the record is an electronic record then a record audit trail must be maintained with the record that includes a time and date history of deletions, edits and/or corrections to electronically signed records.
AMENDATORY SECTION (Amending WSR 95-21-041, filed 10/10/95, effective 11/10/95)
WAC 246-817-310 ((Maintenance and)) Patient 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 shall keep readily accessible patient records for at least six years from the date of the last treatment.
(2) A licensed dentist shall respond to a written request from a patient 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.
(3) 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.
NEW SECTION
WAC 246-817-315 Business records accessibility.
If requested as part of an investigation authorized by the secretary, a licensed dentist who operates a dental practice in the state of Washington shall provide to the secretary:
(1) Documentation that the licensed dentist is:
(a) The owner, purchaser, or lessee of the dental equipment;
(b) The owner, purchaser, or lessee of the office the dentist occupies; and
(c) Associated with other persons in the practice of dentistry, whether or not the associate is licensed to practice dentistry.
(2) All contracts or agreements governing the dental practice business relationships with co-owners, partners, and associates.
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