Protecting your health and your smile 175 Bloor St. E., North Tower, Suite 601, Toronto, ON M4W 3R8 t 416-961-6234 tf 1-800-268-2346 f 416-961-6028 The province of Ontario has committed to implementing a comprehensive electronic health record for all Ontarians, and similar efforts are being made in other provinces and nations. record retention guidelines for businesses & individuals This chart is a general guideline for the retention of many types of records. It may be helpful for dentists to retain a copy of documentation attesting to that person’s signed consent to the release of information to the patient’s family in the patient’s record. Stored records should be kept in a systematic fashion for easy retrieval. Recall History Name: MR. / MISS / MRS. / MS. / DR. Legal Support for Victims of Sexual Abuse, List of Illegal/Unauthorized Practitioners, Sedation and/or General Anesthesia Inspection Program, COVID-19: Managing Infection Risks During In-Person Care, COVID-19 - Guidance for the Use of Teledentistry, Professional Patient-Dentist Relationships, Personal Health Information Protection Act, Practice Name Registration Application Form, Principles for Approved Sponsors and Core Course Presenters, Information on Change of Practice Ownership and Retiring, Information on New Practice Setup and Changing Practice Locations, Information on Prescribing and Dispensing Drugs, Post-Specialty Training Licence/Certificate, Registration Requirements for Int'l Applicants, Finance, Property and Administration Committee, Inquiries, Complaints and Reports Committee. Customs Bulletin and Decisions. Digital images can be provided on removable media or by secure e-mail with strong encryption. These guidelines are designed to educate psychologists and provide a framework for making decisions regarding professional record keeping. Only a dentist can be a custodian of patients’ dental records. If there is any doubt about what the patient has consented for you to release, contact the patient or the new dentist for clarification. To allow for the provision of safe dental care, dentists must ensure that all necessary and relevant medical information is obtained prior to initiating treatment. Dentists do not have to notify patients if their records are stored in the basement of the dental office or other premises that are controlled by the dentist. When a dental office is transitioning from paper records to electronic records, can existing paper records be scanned and destroyed? Toll Free: 800.565.4591 www.rcdso.org. This information may be helpful should a claim or complaint arise at a later date. Health Information) Regulations 1996 set the minimum period for retention of patients’ records. Familiarize themselves with, and have a clear understanding of, the College’s standards of practice, guidelines, practice advisories and other publications Keep their clinical skills sharp and their knowledge base up-to-date through continuing education courses and review of … How long do dentists have to keep dental records? The disposal of electronic patient records must be authorized by the dentist. This is a separate business issue that can be addressed according to the office’s collection policies and protocols. 3. 3.7 . Your general liability or office overhead insurance policy may cover some of these costs. What happens if the request for patient records comes from a family member of a deceased patient? If the patient picks up the records, have the patient sign in the patient’s record that they have received them. Patients are entitled to seek care with other dental health care providers and dentists must provide copies of the dental records as requested by the patients. Describe the steps that you have taken to salvage or reconstruct the dental records and which records remain. If the system cannot be restored from a backup copy, it may be possible to recover data from a damaged hard drive. The Standards for Record Keeping address many of the same requirements that are covered by the Personal Health Information Protection Act, 2004(PHIPA). Dentists must not sell or give away electronic media devices that have stored patient records. If you are referring a patient to another dentist, obtain the patient’s consent in advance for the release of records and the disclosure of personal health information, such as may be required in a referral form or report. A decision to keep working models should be based on the complexity of the case and is left to the judgement of the individual practitioner. Keep it in a secure area in the office, preferably with the drugs, and reconcile it on a routine basis, depending on the nature of the practice and reasonable clinical judgement. College regulations must be followed, regardless of a financial dispute between a patient and a dentist. In most cases, a parent can request and obtain copies of the dental records for children who are under the age of 16 years. However, dentists can decide whether and how long to retain copies of other correspondence with insurance companies about dental insurance claims. There is increasing pressure on all health care professionals to convert from paper records to electronic records. Educational Requirements & Professional Responsibilities for Implant Dentistry. In keeping and maintaining acceptable patient records, the following principles are essential: • All entries sh ould be dated and recorded by hand in permanent ink or typewritten, or be in an acceptable electronic format and “locked” on the date to which they are attributed. If there are large volumes of paper records to sort and dispose of at one time, consider using a shredding or document management company. For electronic records, the College recommends that they be backed-up on a routine basis and stored in a physically secure environment off-site. Anatomy of a Good Dental Record To assist members in creating and maintaining good records, RCDSO published revised Guidelines on Dental Recordkeepingin November 2019. Yes. The Guidelines of the Royal College of Dental Surgeons of Ontario contain practice parameters and standards which You may also provide the College with a report of the incident and the list of patients whose records were stolen. (1) Records management requirements (as described in DoD 5015.02-STD (Reference (i))), issues, and solutions must be identified and linked to their implementing technologies and business processes. Dentists are legally required to keep dental records. Dentists are legally required to keep dental records. Notify police of the theft and report the breach to the Office of the Information and Privacy Commissioner of Ontario. An accurate written record detailing all aspects of patient monitoring is important because it contributes to the circulation of information amongst the different teams involved in the patient's treatment or care. Alternatively, the device may be physically destroyed. Keeping inadequate or inaccurate records is an act of professional misconduct at the Royal College of Dental Surgeons of Ontario (RCDSO). Dental Recordkeeping Guidelines April 2013 Contents 2 Introduction 4 Medical and Dental History 5 Confidentiality 6 Dental Examination 8 Informed Consent 9 reatment T Records 10 Electronic Recordkeeping 11 Financial Records 12 Drug Records 13 Ownership, Retention, Transfer and Disposition of Dental Records Practice Guidelines of the College of Dental Surgeons of BC (CDSBC) should The New Zealand Standard Health Records (NZS 8153:2002) sets out the minimum requirements for the appropriate documentation and management of health records within public and private Dentists should avoid using e-mail to communicate the personal health information of patients, unless they are employing a secure e-mail service with strong encryption. At Ports of Entry. E-mail is not a secure means of communication, and may be vulnerable to interception and hacking by unauthorized third parties. In the case of a minor, these records must be kept for at least ten years after the day the patient turned 18. What financial records must be retained for patients? The RCDSO has recently released new guidelines for dental offices to follow. For example, this may include medical histories, examination findings, radiographs and other diagnostic records required to provide safe and appropriate dental care. Resource: RCDSO, Standard of Practice Infection Prevention and Control in the Dental Office (2018) CDHO Infection Prevention and Control (IPAC) Guidelines (2018) M . Along US Borders. An electronic copy of claim forms on a properly backed-up system is acceptable. hard drives, scanners, printers) are to be disposed, dentists must ensure that all patient records are permanently deleted or irreversibly erased from them. Regulation . Know what you're looking for? If a patient and/or authorized representative requests a copy of the patient’s complete file this information must be provided. A drug register must record and account for all narcotics, controlled drugs, benzodiazepines and targeted substances that are kept on-site at the dental office. An audit trail should maintain a record of the name of the patient whose personal health information was disposed, the time period to which the information relates, and the person responsible for authorizing the disposal of the information. Are there any circumstances where original dental records can be released? What should I do? Clinical and financial patient records, as well as radiographs, consultant reports, and drug and lab prescriptions must be maintained for at least ten years after the date of the last entry in the patient’s record. You should notify (verbally or in writing) patients currently in treatment and other active patients about what has occurred and whether any records may need to be recreated. Informed Compliance Publications. Dentists must protect the patient’s personal health information and should review the company’s privacy policy. Record Keeping Documentation of the sterilization of dental instruments and devices is a critical element of a dental practice’s IPAC program. While a patient may request copies of the dental records for a spouse or a child 16 and over, the dentist will require the consent of these individuals to release their records. Patients are entitled to diagnostic quality duplicate radiographs on film, photographic paper or appropriate digital formats. Once the retention period has passed, how can electronic patient records be disposed in a manner that maintains confidentiality. Border Patrol Sectors. Patients are also entitled to duplicate study models or equivalent diagnostic quality digital images of them. Personnel recordkeeping regulations are found in . Records for which the most recent entry was created on or after June 1, 2013 must be kept for 16 years from the date of last entry. Do I have to release them? Under Ontario’s Personal Health Information Protection Act (PHIPA), the authorized person is the deceased’s estate trustee or the person who has assumed responsibility for the administration of the deceased’s estate. Enter a few keywords and click search. control and record keeping. There is a regular schedule for environmental cleaning in the designated reprocessing area that includes a written policy and procedure and clearly defined responsibilities. • All … Federal Register Notices. Let’s Review the new RCDSO Guidelines Tuesday April 9th 2019 6:30-9PM-SOLD OUT Wednesday April 17th 2019 6:30-9PM-NEW DATE ADDED SOLD OUT Tues… These financial records must be retained for at least ten years from the date of the last entry in that record. Dentists are required to maintain patient confidentiality when disposing of dental records. Home / RCDSO Members / Running Your Practice / Medical History Recordkeeping Medical History Recordkeeping To allow for the provision of safe dental care, dentists must ensure that all necessary and relevant medical information is obtained prior to initiating treatment. This interactive online course will discuss strategies to help improve recordkeeping and patient care in your dental office. Border Security. After the record retention period has passed, how do dentists destroy the records that are no longer needed? There was a flood/fire in my dental office and some of my patients’ dental records were damaged or destroyed. © Copyright 2021 Royal College of Dental Surgeons of Ontario. eRuling Requirements. (2) Records management requirements will be integrated into DoD Component The release and transfer of dental records should be accomplished within one to two weeks of receipt of the request. This may include mailing costs, charges from a dental laboratory or radiograph duplicating facility, and materials costs. Copies of dental claim forms must be kept for at least two years from the date the claim was provided to the patient or submitted on the patient’s behalf. Whether this is possible may depend on the number and type of dental records requested and whether the services of an outside duplication facility (for dental radiographs and study models) are required. A laptop or briefcase containing patients’ records has been stolen. What do I have to do? Legally, the dentist (in a principal-associate arrangement, this is usually the principal/owner of the practice) is deemed to be the custodian of their patients’ dental records. In the event that electronic media (e.g. Clinical and financial patient records, as well as radiographs, consultant reports, and drug and lab prescriptions must be maintained for at least ten years after the date of the last entry in the patient’s record. Specific retention periods should take into account industry requirements and contractual obligations. Keep the register in a secure area in the office, preferably with the drugs. However, the use of electronic records by dentists, including digital radiography, has grown substan - tially in Ontario, and the sophistication of hardware and software has evolved significantly since the Guidelines on Dental Recordkeeping were … Are patients entitled to copies of their dental records? If dental records are required for urgently needed dental treatment at another dental practice and it is not possible to make duplicates in time for the appointment, a dentist may lend original dental records to another dentist at the patient’s request. It is not considered appropriate to charge an administrative fee for the dental staff ’s time. When a dentist dies, what will happens to their patients’ dental records? Among other things, the Guidelines state that patient records must be accurate, comprehensive, legible and accessible. Do dentists need to keep a drug register? Legal Support for Victims of Sexual Abuse, List of Illegal/Unauthorized Practitioners, Sedation and/or General Anesthesia Inspection Program, COVID-19: Managing Infection Risks During In-Person Care, COVID-19 - Guidance for the Use of Teledentistry, Professional Patient-Dentist Relationships, Personal Health Information Protection Act, Practice Name Registration Application Form, Principles for Approved Sponsors and Core Course Presenters, Information on Change of Practice Ownership and Retiring, Information on New Practice Setup and Changing Practice Locations, Information on Prescribing and Dispensing Drugs, Post-Specialty Training Licence/Certificate, Registration Requirements for Int'l Applicants, Finance, Property and Administration Committee, Inquiries, Complaints and Reports Committee. A former patient of mine has requested copies of dental records, but I don’t know where they are. GUIDELINES. Can I give my patients their original dental radiographs or study models? Chart records and other documents must be properly destroyed either by shredding or incineration. Can I charge the patient for the release of dental records? Whenever drugs in these classes are used or dispensed, a record containing the name of the drug, number dispensed, name of the patient and date should be entered in the register. The College advises asking for a document entitled “Coroner’s Authority to Seize During an Investigation”; if one cannot be provided, document the request and the official to whom the dental records have been provided and retain copies of the dental records. Original paper records, dental radiographs and study models for a patient must be retained and maintained as required by the regulations. What would be considered a reasonable time frame for the release of dental records? In addition, record this information in the patient’s clinical records along with any instructions given. That dentist should document the patient’s consent for this, as well as their subsequent return. Confidentiality requirements apply to paper, digital, and other forms of patient information and dental records.Records should be stored securely, not left unattended or in public areas of the office, and destroyed appropriately and securely at the end of the required retention period (See Section VII). ledgers to keep records for their patients. During the course of a missing person or criminal investigation, the Ontario Provincial Police may legally require a dentist to surrender dental records to them by producing a search warrant issued by a judge or a justice of the peace. The College also publishes the Medical History Recordkeeping Guide, which includes additional supporting materials for this key area of … Cargo Security. The first step is to determine which records can be retrieved or salvaged. No. What happens if the request for patient records comes from the police? Canaray's standards of practice aim to meet or exceed all standards of practice set forth by the Royal College of Dental Surgeons of Ontario. Please review your previous medical history (dated / / ) and advise your dentist if there My associate is leaving the practice and some of my patients are asking for their dental records to be released to the associate at his/her new practice location. They must be permanently deleted or irreversibly erased, including any back-up or other copies. In most cases the patient’s new dentist will have provided a request for records signed by the patient. Disputes between practitioners and changes in business arrangements should not hinder patients’ access to the personal health information in the dental records that is needed for their ongoing dental care. Border Patrol History. Other material from insurance companies, such as predeterminations, explanations of benefits and cheque stubs, should be kept until final settlement of the account. What should I do? Can I withhold the release of dental records because a patient did not settle his/her account? The following are the record keeping requirements, all of which fall into the high risk (HR) category: o A log of test results during sterilization is maintained and reviewed. Finally, other APA prac-tice guidelines were examined to ensure internal consis-tency of APA policies. Regularly test your recovery procedures to ensure that all patient records and critical data can be retrieved and reliably restored from the backup copy. Records of Selling a House (Documentation for Capital Gains Tax) Records of Selling a Stock (Documentation for Capital Gains Tax) Receipts, Cancelled Checks and other Documents that Support Income or a Deduction on your Tax Return (Keep 3 years from the date the return was filed or 2 years from the date the tax was paid -- which ever is later) Approved by Council – May 2013 This is replacing the document last published in August 2002. After drafting a proposed revision, COPPS sought feedback and incorporated suggestions from the APA Eth- Yes. In such cases, the original dental records should be sent directly from dentist to dentist by courier and, after consultation and treatment, the original dental records should be returned to the dentist who lent them. You may wish to notify the College, too. Do I have to provide them? records, electronic records, retention of records, and compliance with rapidly changing state and federal re-quirements for record keeping. Yes, if the patient has consented to the release of the records. SEDATION, INFECTION CONTROL, AND RECORD KEEPING. Keep accurate logs of all BI results in accordance with RCDSO record keeping requirements. Financial records should be kept for the same retention period described above. Can the patient pick up copies of their dental records or have them sent to their home? On top of providing guidance for offices to re-open such as preparing the office, providing dental care, aerosol-generating procedures and exposure in the practice, the RCDSO also provides the following updated information: Dentists may discard photographs, radiographs and models in the garbage once patient identification/identifying labels have been removed, obliterated or rendered illegible. In the case of a minor, these records must be kept for at least ten years from the date the patient turned 18 years of age. The request for dental records does not have to originate from another dental office, and dentists can provide copies of dental records to their patients directly if requested. While many dentists will provide copies of dental records at no charge as a courtesy to their patients, a dentist can charge a fee consistent with the direct costs incurred in duplicating and releasing them. OTs must know and understand the record keeping requirements of their specific practice as responsibilities will vary depending on the role each OT assumes under PHIPA. The estate trustee or the person who has assumed responsibility for the administration of the deceased dentist’s estate assumes responsibility for retaining the dental records until they can be transferred to another dentist. You should be honest with the patient about which records are unavailable and make finding them a priority. Your report should be made in writing and you may request that it be placed in your general file, which is retained at the College indefinitely. The Royal College of Dental Surgeons of Ontario (RCDSO) publishes Guidelines on Dental Recordkeeping, which includes a sample medical history questionnaire. Drug Register Dentists must maintain a drug register to record and account for all narcotics, controlled drugs and targeted substances that are kept on-site. 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