Dental Recordkeeping at the RCDSO
Keeping inadequate or inaccurate records is an act of professional misconduct at the Royal College of Dental Surgeons of Ontario (RCDSO). Dentists are the custodians of their patients’ records, and have professional, ethical, and legal responsibilities to document all aspects of dental care. Based on our extensive experience representing dentists, we have prepared this introductory guide to recordkeeping at the RCDSO.
Dentists must keep their records in compliance with the Dentistry Act, 1991 and the RCDSO guidelines. What constitutes compliance will vary from case to case, and the contents of a file should reflect the patient’s dental condition and the complexity of the treatment they require. The following is a non-exhaustive list of what dentists should include in their patient files:
- The patient’s dental history;
- The patient’s general medical history, which can be periodically updated by using a recall history questionnaire;
- Details of patient conversations, including information and recommendations provided to the patient, and decisions made by the patient;
- Any conditions found or reported at the initial examination;
- Details of the assessment and clinical diagnosis;
- Proposed treatment options;
- The accepted treatment plan;
- Details of treatment implementation;
- The outcome of the treatment;
- Details of drugs used and dispensed for patient care, and any instructions provided to the patient (this information will also be included in the practice’s Drug Register);
- Financial records, including any written agreements or arrangements, itemized fee listings, insurance information, and dates of charges and payments; and
- Radiographs, photographs, and diagrams.
Dentists must obtain a patient’s informed consent before proceeding with any treatment, and should include such exchanges in the record. Whenever possible, written and signed consent is ideal, as the RCDSO often receives complaints from patients alleging a lack of consent. When applicable, the record should also note a patient’s refusal to provide consent.
Dentists should never alter any records. Altering records is considered an act of professional misconduct. If dentists neglect important details in earlier chart entries, or must adjust their treatment plans to accommodate changes in circumstances, they should create new entries.
As health information custodians, dentists do not own their patients’ records. Patients are entitled to their records, and failing to transfer records upon a patient’s request is an act of professional misconduct. There are a number of scenarios, including the investigation, retirement, or death of a dentist, in which a patient, another healthcare provider, or the RCDSO may need to review records, and should be able to do so with little difficulty. As a result, patient records must be readily accessible, well-organized, legible, and understandable.
Dentists are subject to Ontario’s privacy legislation, the Personal Health Information Protection Act, 2004. Patient records are private and confidential, and dentists must take reasonable steps to ensure that the records are protected against theft, loss, unauthorized use, disclosure, copying, modification, and disposal. Dentists must also ensure that patient records are retained, transferred, and disposed of in a secure manner that follows regulations. Dentists are responsible for informing their staff of their duties and privacy obligations.
If transferring or releasing records to a third-party, or discussing a patient’s conditions or treatment needs with a third-party, dentists or their staff must obtain the consent of the patient or a substitute decision maker. Dentists should also record any referrals to specialists, copies of reports or correspondence with specialists, and summaries of oral conversations about the patient. If there is any doubt as to whether or not a patient provided consent, or the extent of their consent, dentists should seek clarification from the patient or their substitute decision maker.
In contrast to the above, dentists do not need patient consent to release records to the RCDSO during a formal complaint investigation, but are obligated to provide the records. Failure to cooperate with the RCDSO investigation is an act of professional misconduct. Dentists enclose patient records with their written response, and these documents are reviewed by the RCDSO’s Inquiries, Complaints and Reports Committee (ICRC). Regardless of whether or not the ICRC determines that the care provided to a patient was appropriate, it may still evaluate the quality of a dentist’s records. A negative finding by the ICRC can impact a dental career, so dentists who are subject to a complaint should consider contacting legal counsel.
Dentists are increasingly digitizing their files and relying on electronic records, which must also comply with the same guidelines as paper records. However, electronic records pose unique security and privacy risks, and require extra safeguards, software, and practice management solutions. When transferring from paper records to electronic records, dentists must retain originals and back up electronic versions. Electronic records must be authentic, reliable, useable, and protected against unauthorized alteration. Dentists should use an Electronic Records Management System to help meet their privacy requirements.
In storing records, dentists must take reasonable steps to prevent unauthorized access, theft, or damage. Patient consent is required to keep records off-site. Regardless of the location, dentists must keep records in a secure place, yet ensure that they are accessible. Failing to provide a patient with their records and radiographs in a reasonable amount of time is an act of professional misconduct. If dentists cannot locate a record, or if a record is damaged or destroyed, they should notify the relevant patient, and work to rectify the situation.
Generally, dentists must maintain all patient records for at least 10 years from the date of the last entry or, in the case of a minor, at least 10 years from the date on which the patient reached 18 years of age. After the record retention period has passed, dentists must maintain patient privacy and confidentiality, and only dispose of records through shredding or incineration.
The RCDSO offers a course on dental recordkeeping that can be taken voluntarily. In cases in which a complaint has been made and the ICRC has concerns about a dentist, it can order course completion as a Specified Continuing Education or Remediation Program (SCERP).
Proper recordkeeping benefits patients, providing more context and information for dentists’ decision making and treatment plans. Keeping accurate records also benefits dentists, providing documentary evidence when defending against any potential complaints or civil lawsuits. It may be prudent for dentists to contact legal counsel, as a lawyer can help determine the unique recordkeeping obligations in each case. Whether or not dentists are subject to formal complaints at the RCDSO, diligent recordkeeping is a necessity.