Section 338.11120. Dental treatment records; requirements.

 (1)   A dentist shall make and maintain a dental treatment record on each patient.

(2)          The  dental  treatment  records  for   patients  shall  include  all   of  the  following information:

(a)     Medical and dental history.

(b)      The patient’s existing oral health care status and the results of any diagnostic aids used.

(c)     Diagnosis and treatment plan.

(d)    Dental procedures performed upon the patient, that specify both of the following:

(i)     The date the procedure was performed.

(ii)     Identity of the dentist or the dental auxiliary performing each procedure.

(e)      Progress notes that include a chronology of the patient’s progress throughout the course of all treatment.

(f)     The date, dosage, and amount of any medication or drug prescribed, dispensed, or administered to the patient.

(g)        Radiographs taken in the course of treatment. If radiographs are transferred to another dentist, the name and address of that dentist shall be entered in the treatment record.

(3)     All dental treatment records shall be permanent and shall be maintained for not less than 10 years from the date of the last treatment provided.

History: 1989 AACS; 2014 AACS.