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Regulatory & Compliance : Patient Records

Retention of Patient Records 

44:04:09:08.  Retention of medical or care records. A health care facility must retain medical or care records for a minimum of ten years from the actual visit date of service or resident care. The retention of the record for ten years is not affected by additional and future visit dates. Records of minors must be retained until the minor reaches the age of majority plus an additional two years, but no less than ten years from the actual visit date of service or resident care. Initial, annual, and significant-change resident assessment records, as required in §§ 44:04:06:15 and 44:04:06:16, must be retained for ten years from the actual visit date of resident care. The retention of the record for ten years is not affected by additional and future visit dates.

44:04:09:09.  Storage of medical or care records. A health care facility must provide for filing, safe storage, and easy accessibility of medical or care records. The medical or care records must be preserved as original records or in other readily retrievable and reproducible form. Medical or care records must be protected against access by unauthorized individuals. All medical or care records must be retained by the health care facility upon change of ownership.
 
Transfer of Patient Records 
 
SDCL 36-2-16. Medical records released to patient or designee on request - - Expenses paid by patient - - Violation as misdemeanor. A licensee of the healing arts shall provide copies of all medical records, reports, and x-rays pertinent to the health of the patient, if available, to a patient or the patient's designee upon receipt by the licensee of a written request or a legible copy of a written request signed by the patient. A violation of this section is a Class 2 misdemeanor. The licensee may require before delivery that the patient pay the actual reproduction and mailing expense.
 
ADA's Principles of Ethics and Code of Professional Conduct: III.1.B.1. Furnishing copies of records. A dentist has the ethical obligation on request of either the patient or the patient's new dentist to furnish, either gratuitously or for nominal cost, such dental records or copies or summaries of them, including dental x-rays or copies of them, as will be beneficial for the future treatment of the patient. This obligation exists whether or not the patient's account is paid in full.

Risk management experts offer the following recommendations for dentists who are asked to transfer patient records to other dentists, physicians, or attorneys:
 
1)  Be certain the patient is aware of the request and has authorized it. Ask the patient to sign a release statement that will protect the confidentiality of the dentist-patient relationship;
 
2)  Do not send original records, except under court order;
 
3)  The information sent to another dentist does not have to include the entire record. If, for instance, a patient has been with a dentist 17 years, records for all those years may not have to be sent to facilitate future care. Radiographs and records for the past two or three years, plus a summary of care provided during the previous 14 years, may be sufficient; and
 
4)  A dentist cannot refuse to transfer any of the records or other information pertinent to treatment for any reason, even if there is an unpaid balance or fear that the patient might initiate litigation.
 
 

SDDA News

Changes to the Dental Practice Act Proposed

The South Dakota Board of Dentistry is in the midst of a rewrite of the South Dakota Dental Practice Act. It has been nearly 20 years since the last major update to the Practice Act. The SDDA has formed a task force to review the Board's proposed changes and to provide insight and recommendations to both the Board of Dentistry and the SDDA Board of Trustees. A draft of the Board's proposed changes can be requested from the Board at:contactus@sdboardofdentistry.com