This case study involving a dentist who refused to provide a complete copy of a patient’s dental records demonstrates the value of knowing the rules concerning dental records and complying with state and federal laws. The discussion includes strategies to help dental professionals avoid complaints, investigations, and sanctions.
An adult patient discussed a complex treatment plan with the dentist but did not agree with the dentist’s recommendations. The patient subsequently decided to consult with another dental provider for a second opinion. The patient requested a complete copy of the dental records from the original dentist to help expedite the consultation, but the dentist refused, stating that the patient had not paid the full amount of the dental fees and had an outstanding balance remaining on the account.
The patient filed a complaint with the state’s dental board. After receiving a letter of investigation, the dentist provided the patient with a copy of the dental records but did not include copies of the x-rays. The board investigator suggested that the dentist consult an attorney. The attorney confirmed the requirement to provide copies of the patient’s complete dental record—including copies of the x-rays. The dentist complied.
Risk Management Discussion
Many states have statutes or administrative code provisions governing the content of dental records. The content requirements may include patient history; x-rays; dental examinations; test results; drugs prescribed, dispensed, or administered; relevant comorbidities; consultation reports; and any other documentation that the dentist relies on to treat the patient.
It is not appropriate for any healthcare practitioner to withhold requested records or portions of a record because a patient has an outstanding balance for services rendered, disputes the treatment provided, or disagrees with fees that have been charged. With very few exceptions, patients are entitled to a complete record set maintained by the practice pursuant to federal and state law. It is important to know the rules concerning dental records in the jurisdiction in which you practice, including the requirements for their minimum content, retention, storage, and release.
Additionally, dental offices that submit electronic claims, eligibility requests, claim status inquiries, and requests for authorization are also governed by HIPAA privacy, security, and breach notification rules. (See our accredited education course catalog for complimentary dental education courses on HIPAA Fundamentals and HIPAA for Managers.)
The following strategies can help dental professionals avoid patient complaints, governmental investigations, administrative sanctions, and adverse social media postings when responding to record requests:
- If you receive an oral request for dental records, either in person or by telephone (including from a law enforcement representative), respectfully and politely tell the individual that all requests for records must be submitted in writing (on official letterhead, if appropriate). Tell the individual that, once you receive the written request, it will be reviewed as soon as possible.
- Do not unilaterally refuse to provide records to a properly authorized individual who presents an appropriate written request. Seek advice from your professional liability carrier, risk manager, corporate counsel, or personal attorney. Withholding records can antagonize the patient and irreparably injure the patient-practitioner relationship. It may also result in a complaint to your state dental licensing board, state department of consumer affairs, or even the federal Office of Civil Rights.
- Respond promptly to requests for records. You are not expected to provide the material on short notice, but you are required to respond in a timely manner, as defined under applicable state law and in the HIPAA Privacy Rules.
For more strategies on patient record issues, read “The Defensible Medical Record.” For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.