Are patients entitled to copies of their dental records?
Patients are entitled to copies of any or all of their dental records. If a patient and/or authorized representative requests a copy of the patient’s complete file this information must be provided. The request for dental records does not have to originate from another dental office, and dentists can provide copies of dental records to their patients directly if requested. The requests made by patients and the release of dental records should be documented in the patients’ records.
Yes, if the patient has consented to the release of the records. In most cases the patient’s new dentist will have provided a request for records signed by the patient. If there is any doubt about what the patient has consented for you to release, contact the patient or the new dentist for clarification. 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.
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. If the patient picks up the records, have the patient sign in the patient’s record that they have received them. If someone else arrives to pick up the patient’s records from your office, ensure that you have the patient’s consent to release them. The patient can indicate this in advance with their signed consent.
Dentists are required by law to keep records. Patients are entitled to diagnostic quality duplicate radiographs on film, photographic paper or appropriate digital formats. Patients are also entitled to duplicate study models or equivalent diagnostic quality digital images of them. Digital images can be provided on removable media or by secure e-mail with strong encryption.
In most cases, a parent can request and obtain copies of the dental records for children who are under the age of 16 years. While a patient may request copies of the dental records for a spouse or a child 16 and over, the dentist will require the consent of these individuals to release their records.
The release and transfer of dental records should be accomplished within one to two weeks of receipt of the request. 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.
No. It is unacceptable to withhold the transfer of records because of an outstanding account balance. This is a separate business issue that can be addressed according to the office’s collection policies and protocols. College regulations must be followed, regardless of a financial dispute between a patient and a dentist.
Disputes between practitioners and changes in business arrangements should not hinder patients’ access to the personal health information in the dental records that is needed for their ongoing dental care. In most cases (unless otherwise agreed to in writing), principal dentists retain the patients’ original dental records and must provide copies of the records to former associates as requested and consented to by the patients.
Yes, if the patient has consented to the release of the records. Patients are entitled to seek care with other dental health care providers and dentists must provide copies of the dental records as requested by the patients.
If original dental records are required for a coroner’s investigation, they can be released. 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.
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 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. That dentist should document the patient’s consent for this, as well as their subsequent return.
The dentist needs to determine who is legally authorized to consent to the release of the patient’s personal health information. 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. It may be helpful for dentists to retain a copy of documentation attesting to that person’s signed consent to the release of information to the patient’s family in the patient’s record.
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. Health information custodians may also disclose personal health information to police without a warrant in limited circumstances outlined in PHIPA.
Dentists are legally required to keep dental records. 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. In the case of a minor, these records must be kept for at least ten years after the day the patient turned 18.
The same retention period applies to appointment books and other office records (such as equipment maintenance records, sterilization log and drug register).
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. Only a dentist can be a custodian of patients’ dental records.
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.
These financial records must be retained for at least ten years from the date of the last entry in that record. In the case of a minor, these records must be kept for at least ten years from the date the patient turned 18 years of age.
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. An electronic copy of claim forms on a properly backed-up system is acceptable. 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. Working models do not have to be retained for any specific period of time. 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.
Yes. 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. Whenever drugs in these classes are used or dispensed, a record containing the name of the drug, number dispensed, name of the patient and date should be entered in the register. Each entry should be initialled or attributable to the person who made the entry. In addition, record this information in the patient’s clinical records along with any instructions given. Keep the register in a secure area in the office, preferably with the drugs.
Dentists are required to maintain patient confidentiality when disposing of dental records. Chart records and other documents must be properly destroyed either by shredding or incineration. If there are large volumes of paper records to sort and dispose of at one time, consider using a shredding or document management company. Dentists must protect the patient’s personal health information and should review the company’s privacy policy. Dentists may discard photographs, radiographs and models in the garbage once patient identification/identifying labels have been removed, obliterated or rendered illegible. Recycling is not a secure method of disposing of records.
The estate trustee or the person who has assumed responsibility for the administration of the deceased dentist’s estate assumes responsibility for retaining the dental records until they can be transferred to another dentist.
Yes. 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. Stored records should be kept in a systematic fashion for easy retrieval. Dentists do not have to notify patients if their records are stored in the basement of the dental office or other premises that are controlled by the dentist. If stored off-site, patient consent must be obtained.
The first step is to determine which records can be retrieved or salvaged. There are companies that specialize in recovery and reconstruction of paper records and data recovery of electronic records. Your general liability or office overhead insurance policy may cover some of these costs.
For electronic records, the College recommends that they be backed-up on a routine basis and stored in a physically secure environment off-site. Regularly test your recovery procedures to ensure that all patient records and critical data can be retrieved and reliably restored from the backup copy. If the system cannot be restored from a backup copy, it may be possible to recover data from a damaged hard drive.
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. For example, this may include medical histories, examination findings, radiographs and other diagnostic records required to provide safe and appropriate dental care. You may wish to notify the College, too. This information may be helpful should a claim or complaint arise at a later date. Describe the steps that you have taken to salvage or reconstruct the dental records and which records remain. 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.
You should be honest with the patient about which records are unavailable and make finding them a priority. If you cannot locate the records and they are necessary for treatment at another office, offer to retake only the necessary radiographs and re-examine the patient at no charge to provide the diagnostic information requested and required to continue or complete their treatment, whether at your dental practice or elsewhere.
Notify police of the theft and report the breach to the Office of the Information and Privacy Commissioner of Ontario. The IPC/ON has a breach notification assessment tool that guides dentists in evaluating whether they have a legal obligation to notify about the loss of their personal health information. In most cases, notification is required. You may also provide the College with a report of the incident and the list of patients whose records were stolen.
Original paper records, dental radiographs and study models for a patient must be retained and maintained as required by the regulations.
E-mail is not a secure means of communication, and may be vulnerable to interception and hacking by unauthorized third parties. 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.
Alternatively, digital radiographic files can be saved and delivered on medium such as a CD-ROM or USB key.
The disposal of electronic patient records must be authorized by the dentist. They must be permanently deleted or irreversibly erased, including any back-up or other copies. An audit trail should maintain a record of the name of the patient whose personal health information was disposed, the time period to which the information relates, and the person responsible for authorizing the disposal of the information.
In the event that electronic media (e.g. hard drives, scanners, printers) are to be disposed, dentists must ensure that all patient records are permanently deleted or irreversibly erased from them. Alternatively, the device may be physically destroyed.
Dentists must not sell or give away electronic media devices that have stored patient records.
