A dentist who treats patients shall maintain legible, complete, and accurate medical records. The medical record must contain the patient’s clinical and financial record. The clinical record must contain the following information:

1. (1) For each clinical record entry note:

   1. (a) The signature, initials, or electronic verification of the individual that made the entry note; and
   2. (b) If treatment was provided, the name and the signature, initials, or electronic verification of the individual that provided treatment;
2. (2) The date of each patient record entry, document, radiograph or model;
3. (3) The examination findings documented by subjective complaints, objective findings, an assessment or diagnosis of the patient's condition, and proposed treatment options;
4. (4) Current dental and medical history that may affect dental treatment;
5. (5) Any images, radiographs, test results or other diagnostic aid used to aid in the diagnosis. All film or digital radiographs must be of diagnostic quality. Retention of molds or study models is at the discretion of the dentist, except for molds or study models for orthodontia or full mouth reconstruction that must be retained as part of the clinical record;
6. (6) An agreed upon treatment plan based on the assessment or diagnosis of the patient's condition;
7. (7) A complete description of all treatment or procedures administered to the patient at each visit;

8. (8) A record of any medication administered or dispensed in office, or prescribed, including:

   1. (a) The date administered, dispensed, or prescribed;
   2. (b) The name of the patient to which the medication was administered, dispensed, or prescribed;
   3. (c) The name of the medication; and
   4. (d) The dosage and amount of the medication administered, dispensed, or prescribed, including refills;
9. (9) Referrals, patient response to referrals, and any communication to and from any health care provider regarding the patient;

10. (10) Notation of communication to and from the patient or patient's parent or guardian, including:

    1. (a) Notation of informed consent, including communication of potential risks and benefits of proposed treatment, recommended tests, and alternatives to treatment, including no treatment or tests;
    2. (b) Notation of post-treatment instructions or reference to an instruction pamphlet given to the patient;
    3. (c) Notation regarding patient complaints or concerns associated with treatment, including complaints or concerns obtained in person, by phone call, mail, electronic communication, or digital communication; and
    4. (d) Termination of the doctor-patient relationship; and
11. (11) A copy of, or notation regarding, each laboratory order.

Source: 50 SDR 125 , effective May 8, 2024 .

General Authority: SDCL 36-6A-14 (20).

Law Implemented: SDCL 36-6A-1 (6), 36-6A-14 (1) .