Section 246-812-310. Record content.

(1) A licensed denturist who treats patients shall maintain legible, complete, and accurate patient records.

(2) The patient record must reflect diagnosis, treatment performed, and financial records.

(3) The patient record must include at least the following information:

(a) For each record entry, documented verification or signature by the responsible denturist;

(b) The date of each patient record entry, document, radiograph or model;

(c) Up-to-date treatment plan;

(d) The physical examination findings documented by subjective complaints, objective findings, and an assessment or diagnosis of the patient's condition;

(e) An up-to-date dental and medical history that may affect treatment;

(f) Any diagnostic aid used including, but not limited to, images, radiographs, and recommended tests and test results. Retention of molds or study models for full mouth reconstruction is at the discretion of the denturist;

(g) A complete description of all treatment/procedures administered at each visit;

(h) Referrals and any communication to and from any health care provider; and

(i) Notation of communication to or from patients or patient guardians, including:

(i) Notation or documentation of the discussion of potential risk(s) and benefit(s) of proposed treatment and alternative to treatment, including no treatment;

(ii) Post treatment instructions;

(iii) Patient complaints and resolutions; and

(iv) Termination of denturist-patient relationship.

(4) A patient record may contain manual or electronic treatment notes:

(a) Complete manual treatment notes must not be erased or deleted from the record.

(i) Mistaken manual entries must be corrected with a single line drawn through the incorrect information.

(ii) New or corrected information must be initialed and dated.

(b) Complete electronic treatment notes must include deletions, edits, and corrections.

[Statutory Authority: Chapter 18.30 RCW and 2013 c 171. WSR 14-24-033, § 246-812-310, filed 11/24/14, effective 12/25/14.]

Chapter 18.30 RCW and 2013 c 171. WSR 14-24-033, § 246-812-310, filed 11/24/14, effective 12/25/14.