1. A. Each patient’s clinical chart shall include at a minimum the following:

   1. (1) Patient's name and date of treatment;
   2. (2) Reasons for the patient’s visit;
   3. (3) Treatment plans that are signed and dated by both the treating dentist and the patient;
   4. (4) Patient’s complaints;
   5. (5) Diagnosis and treatment notes;
   6. (6) Progress notes;
   7. (7) Post operative instructions;
   8. (8) Study models;
   9. (9) In-person conversations, telephone conversations, and other correspondence with the patient or their representative;
   10. (10) Identification of medications prescribed, administered, dispensed, quantity, and directions for use;

   11. (11) Clinical details with regard to the administration of:

       1. (a) Nitrous oxide;
       2. (b) Anxiolytics;
       3. (c) Sedation; and
       4. (d) General anesthesia.
   12. (12) Radiographs of diagnostic quality;
   13. (13) Periodontal charting;
   14. (14) Laboratory work authorization forms and correspondence to and from laboratories;
   15. (15) Informed consent;
   16. (16) Copies of correspondence and reports provided to other health care providers, diagnostic facilities, and legal representatives;
   17. (17) Records and reports provided by other health care providers and diagnostic facilities;
   18. (18) Details regarding referrals and consultations;
   19. (19) Patient complaints pertaining to the dentist and staff, and their manner of resolution;
   20. (20) Noncompliance and missed appointment notes; and
   21. (21) Dismissal letter.
2. B. A dentist who performs diabetes or blood pressure screening shall include the results of the screenings in the patient’s clinical chart.

Authority: Health Occupations Article, §4-205(c)(3), Annotated Code of Maryland

Effective date: June 11, 2012 (39:11 Md. R. 687)

Regulation .01-1 adopted effective April 29, 2013 (40:8 Md. R. 724)

Regulation .02 amended effective April 29, 2013 (40:8 Md. R. 724)

Regulation .03 amended effective April 29, 2013 (40:8 Md. R. 724)