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The patient dental record is a history of the patient’s dental treatment, and includes radiographs and models. It is the dentist’s best defense against malpractice allegations. Most liability carriers have specific guidelines on retention of patient records.
Retention Requirements in California
Section 123145 of the California Health and Safety Code states that the minimum retention time of patient records is seven years only if the dentist ceases operation. Beyond that, California law does not specify the period of time that patient records must be maintained after the patient discontinues treatment.
Because an allegation of professional negligence can arise long after treatment is completed, ideally patient records should be maintained indefinitely. Many liability insurance carriers recommend that patient records be kept for a minimum of seven years from the date an adult patient was last seen; and seven years after a minor patient’s last treatment, or when the minor patient turns 25, whichever is longer.
After the recommended retention time, the records may be shredded or otherwise disposed in a manner that makes the protected health information indecipherable. Do not simply throw them in the trash. Care must be taken to maintain the confidentiality of the protected health information.
When searching for a records disposal company, look for companies listed as specializing in dental or medical record storage or disposal. Because of the silver content, radiographs should be disposed of through a silver recycler. Keep a log of when and which records have been disposed.
Storage of Records
For most dentists, storage space is limited, which means that finding space to keep patients’ records can be challenging. Records of active patients should be kept immediately accessible. If onsite storage of inactive patients’ charts is not an option, store records offsite in a secured location. Or consider using digital files. Inactive patients are considered to be individuals who have not returned for treatment within the last 24-36 months.
Consult with your liability insurance carrier on specific recommendations for retaining and disposing of patient records.
Since 1992, OSHA Review, Inc. has provided dental professionals with comprehensive programs to support regulatory compliance and infection control. We are a registered continuing education provider in the state of California, specializing in Dental Practice Act, infection control, and OSHA training.