1. (A) A dentist shall:

   1. (1) maintain timely, legible, accurate, and complete patient records; and
   2. (2) timely provide these records to the patient, another dentist, or a designated medical professional in response to a lawful request for the records by the patient or his legal representative or designee.
2. (B) A dental practice must have a procedure for initiating and maintaining a health record for every patient evaluated or treated. For procedures requiring patient consent, there must be an informed consent documented in the patient record.

3. (C) The health record of a patient required under subsection (B) must include appropriate information to:

   1. (1) identify the patient, support the diagnosis, and justify the treatment;
   2. (2) identify the procedure code or suitable narrative description of the procedure; and
   3. (3) document the outcome and required follow-up care.

4. (D) If moderate sedation or deep sedation/general anesthesia is provided, the health record of a patient also must include documentation of:

   1. (1) patient weight;
   2. (2) type of anesthesia used;
   3. (3) type and dosage of drugs administered, if any;
   4. (4) fluid administered, if any;
   5. (5) a record of vital signs monitoring;
   6. (6) patient level of consciousness during the procedure;
   7. (7) duration of the procedure;
   8. (8) complications related to the procedure or anesthesia, if any; and
   9. (9) time-oriented anesthesia record.

HISTORY: 2014 Act No. 222 (S.1036), Section 2, eff January 1, 2015.