Who should I notify if patient records are damaged or destroyed? A laptop or briefcase containing patients’ records has been stolen. 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. Alternatively, digital radiographic files can be saved and delivered on medium such as a CD-ROM or USB key. 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. Retention of records. Notify police of the theft and report the breach to the Office of the Information and Privacy Commissioner of Ontario. Dentists are required by law to keep records. 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. Approved by Council – May 2013 This is replacing the document last published in August 2002. 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. This information may be helpful should a claim or complaint arise at a later date. However, the privacy legislation requires that patients’ dental records be stored in secure premises to prevent unauthorized access and dentists should take reasonable steps to protect them from theft and damage from fire or flood. The release and transfer of dental records should be accomplished within one to two weeks of receipt of the request. After drafting a proposed revision, COPPS sought feedback and incorporated suggestions from the APA Eth- 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. 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. Chart records and other documents must be properly destroyed either by shredding or incineration. SEDATION, INFECTION CONTROL, AND RECORD KEEPING. 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 Enter a few keywords and click search. In most cases, a parent can request and obtain copies of the dental records for children who are under the age of 16 years. For electronic records, the College recommends that they be backed-up on a routine basis and stored in a physically secure environment off-site. (2) Records management requirements will be integrated into DoD Component Can I withhold the release of dental records because a patient did not settle his/her account? It is unacceptable to withhold the transfer of records because of an outstanding account balance. Recall History Name: MR. / MISS / MRS. / MS. / DR. What happens if the request for patient records comes from a family member of a deceased patient? Financial records should be kept for the same retention period described above. An electronic copy of claim forms on a properly backed-up system is acceptable. This interactive online course will discuss strategies to help improve recordkeeping and patient care in your dental office. 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. 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. In the event that electronic media (e.g. Please review your previous medical history (dated / / ) and advise your dentist if there If stored off-site, patient consent must be obtained. That dentist should document the patient’s consent for this, as well as their subsequent return. Dentists are required to maintain patient confidentiality when disposing of dental records. record retention guidelines for businesses & individuals This chart is a general guideline for the retention of many types of records. 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… ledgers to keep records for their patients. There is increasing pressure on all health care professionals to convert from paper records to electronic records. 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. 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: 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. The dentist needs to determine who is legally authorized to consent to the release of the patient’s personal health information. If there are large volumes of paper records to sort and dispose of at one time, consider using a shredding or document management company. It is not considered appropriate to charge an administrative fee for the dental staff ’s time. Your general liability or office overhead insurance policy may cover some of these costs. Maintenance of a Learning Portfolio (Required for Option 1, Recommended for Options 2 and 3) Dental hygienists planning to submit their Quality Assurance information under Option 1 must maintain a Learning Portfolio and complete continuing quality improvement (CQI) activities that are sufficient to ensure 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. Other material from insurance companies, such as predeterminations, explanations of benefits and cheque stubs, should be kept until final settlement of the account. Diagnostic or study models are considered part of the patient’s record and must be kept for the same retention period prescribed by the regulations. 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. Strategic Plan. GUIDELINES. Are there any circumstances where original dental records can be released? These regulations establish policies and minimum requirements governing the 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. Describe the steps that you have taken to salvage or reconstruct the dental records and which records remain. If there is any doubt about what the patient has consented for you to release, contact the patient or the new dentist for clarification. What should I do? The College also publishes the Medical History Recordkeeping Guide, which includes additional supporting materials for this key area of … Good record keeping is an important aspect for health and social care professionals. © Copyright 2021 Royal College of Dental Surgeons of Ontario. 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 … Alternatively, the device may be physically destroyed. You may wish to notify the College, too. In the case of a minor, these records must be kept for at least ten years after the day the patient turned 18. Customs Bulletin and Decisions. Working models do not have to be retained for any specific period of time. How long do dentists have to keep dental records? Educational Requirements & Professional Responsibilities for Implant Dentistry. 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. records, electronic records, retention of records, and compliance with rapidly changing state and federal re-quirements for record keeping. 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. Keep accurate logs of all BI results in accordance with RCDSO record keeping requirements. The Standards for Record Keeping address many of the same requirements that are covered by the Personal Health Information Protection Act, 2004(PHIPA). Do dentists need to keep a drug register? Record Keeping Documentation of the sterilization of dental instruments and devices is a critical element of a dental practice’s IPAC program. E-mail is not a secure means of communication, and may be vulnerable to interception and hacking by unauthorized third parties. 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. 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. Profile (Reference (h)), and statutory requirements. Guidelines: Electronic Records Management. Each entry should be initialled or attributable to the person who made the entry. The first step is to determine which records can be retrieved or salvaged. This information should be collected systematically, recording the patient’s present state of health and any serious illnesses, conditions or adverse reactions in the past that might affect the dental management of a patient. The College also produced the Medical History Recordkeeping Guide, which includes additional supporting materials for this key area of dental practice, including: © Copyright 2021 Royal College of Dental Surgeons of Ontario. Recycling is not a secure method of disposing of records. 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. Personnel recordkeeping regulations are found in . Health information custodians may also disclose personal health information to police without a warrant in limited circumstances outlined in PHIPA. When a dental office is transitioning from paper records to electronic records, can existing paper records be scanned and destroyed? 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. Border Patrol History. If a patient and/or authorized representative requests a copy of the patient’s complete file this information must be provided. part 293 of title 5, Code of Federal Regulations. You should retain these records according to the following guidelines: Car records (keep until car sold) Credit card receipts (keep until reconciled on your credit card statement) ATM and deposit slips (keep until reconciled on your bank statement) Digital images can be provided on removable media or by secure e-mail with strong encryption. Are patients entitled to copies of their dental records? 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 disposal of electronic patient records must be authorized by the dentist. Dentists must protect the patient’s personal health information and should review the company’s privacy policy. Dental Recordkeeping Online Course. Border Patrol Sectors. If the system cannot be restored from a backup copy, it may be possible to recover data from a damaged hard drive. Yes, the patient can pick up copies of their dental records from your office or request that they be forwarded by registered mail or courier to their home. 3. However, dentists can decide whether and how long to retain copies of other correspondence with insurance companies about dental insurance claims. Border Security. Can I charge the patient for the release of dental records? Finally, other APA prac-tice guidelines were examined to ensure internal consis-tency of APA policies. Know what you're looking for? What would be considered a reasonable time frame for the release of dental records? 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. Can a patient request copies of the dental records for his/her spouse and/or children? 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 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. College regulations must be followed, regardless of a financial dispute between a patient and a dentist. In most cases, notification is required. The financial record must include a copy of any written agreement with the patient and provide an accurate statement of the patient’s account, including the date and amount of all fees charged, commercial laboratory fees, payments received (including the method of payments) and any adjustments to the account. Stored records should be kept in a systematic fashion for easy retrieval. From the … Patients are entitled to copies of any or all of their dental records. The same retention period applies to appointment books and other office records (such as equipment maintenance records, sterilization log and drug register). Health Information) Regulations 1996 set the minimum period for retention of patients’ records. 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. 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. And materials costs: 800.565.4591 www.rcdso.org, they can be a custodian of patients records... 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