rcdso record keeping guidelines

Border Patrol History. E-mail is not a secure means of communication, and may be vulnerable to interception and hacking by unauthorized third parties. records, electronic records, retention of records, and compliance with rapidly changing state and federal re-quirements for record keeping. Can I withhold the release of dental records because a patient did not settle his/her account? What would be considered a reasonable time frame for the release of dental records? 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. 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. Please review your previous medical history (dated / / ) and advise your dentist if there What do I have to do? 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. Strategic Plan. There was a flood/fire in my dental office and some of my patients’ dental records were damaged or destroyed. 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. Recycling is not a secure method of disposing of records. The inspector has a checklist with each of the report requirements, and will check off each item for each report. 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. Enter a few keywords and click search. If original dental records are required for a coroner’s investigation, they can be released. 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. (2) Records management requirements will be integrated into DoD Component An accurate written record detailing all aspects of patient monitoring is important because it contributes to the circulation of information amongst the different teams involved in the patient's treatment or care. 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. Other material from insurance companies, such as predeterminations, explanations of benefits and cheque stubs, should be kept until final settlement of the account. Approved by Council – May 2013 This is replacing the document last published in August 2002. Legal Support for Victims of Sexual Abuse, List of Illegal/Unauthorized Practitioners, Sedation and/or General Anesthesia Inspection Program, COVID-19: Managing Infection Risks During In-Person Care, COVID-19 - Guidance for the Use of Teledentistry, Professional Patient-Dentist Relationships, Personal Health Information Protection Act, Practice Name Registration Application Form, Principles for Approved Sponsors and Core Course Presenters, Information on Change of Practice Ownership and Retiring, Information on New Practice Setup and Changing Practice Locations, Information on Prescribing and Dispensing Drugs, Post-Specialty Training Licence/Certificate, Registration Requirements for Int'l Applicants, Finance, Property and Administration Committee, Inquiries, Complaints and Reports Committee. Financial records should be kept for the same retention period described above. An electronic copy of claim forms on a properly backed-up system is acceptable. The College also publishes the Medical History Recordkeeping Guide, which includes additional supporting materials for this key area of … Can I charge the patient for the release of dental records? Patients are also entitled to duplicate study models or equivalent diagnostic quality digital images of them. College regulations must be followed, regardless of a financial dispute between a patient and a dentist. 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. Notify police of the theft and report the breach to the Office of the Information and Privacy Commissioner of Ontario. 3. Regulation . Educational Requirements & Professional Responsibilities for Implant Dentistry. The requests made by patients and the release of dental records should be documented in the patients’ records. Resource: Copies of paper dental claim forms must be maintained for at least two years. Digital images can be provided on removable media or by secure e-mail with strong encryption. A laptop or briefcase containing patients’ records has been stolen. 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. Know what you're looking for? You should be honest with the patient about which records are unavailable and make finding them a priority. 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. Once the retention period has passed, how can electronic patient records be disposed in a manner that maintains confidentiality. In the event that electronic media (e.g. Home / RCDSO Members / Running Your Practice / Medical History Recordkeeping Medical History Recordkeeping To allow for the provision of safe dental care, dentists must ensure that all necessary and relevant medical information is obtained prior to initiating treatment. Confidentiality requirements apply to paper, digital, and other forms of patient information and dental records.Records should be stored securely, not left unattended or in public areas of the office, and destroyed appropriately and securely at the end of the required retention period (See Section VII). From the … 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. Canaray's standards of practice aim to meet or exceed all standards of practice set forth by the Royal College of Dental Surgeons of Ontario. Patients are entitled to copies of any or all of their dental records. 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. In the case of a minor, these records must be kept for at least ten years after the day the patient turned 18. After the record retention period has passed, how do dentists destroy the records that are no longer needed? Yes, if the patient has consented to the release of the records. On top of providing guidance for offices to re-open such as preparing the office, providing dental care, aerosol-generating procedures and exposure in the practice, the RCDSO also provides the following updated information: Can the patient pick up copies of their dental records or have them sent to their home? There are companies that specialize in recovery and reconstruction of paper records and data recovery of electronic records. Are patients entitled to copies of their dental records? Dental Recordkeeping Online Course. Dentists may discard photographs, radiographs and models in the garbage once patient identification/identifying labels have been removed, obliterated or rendered illegible. Retention of records. Chart records and other documents must be properly destroyed either by shredding or incineration. The following are the record keeping requirements, all of which fall into the high risk (HR) category: o A log of test results during sterilization is maintained and reviewed. You should retain these records according to the following guidelines: Car records (keep until car sold) Credit card receipts (keep until reconciled on your credit card statement) ATM and deposit slips (keep until reconciled on your bank statement) (1) Records management requirements (as described in DoD 5015.02-STD (Reference (i))), issues, and solutions must be identified and linked to their implementing technologies and business processes. Your general liability or office overhead insurance policy may cover some of these costs. All Rights Reserved. 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. The Standards for Record Keeping address many of the same requirements that are covered by the Personal Health Information Protection Act, 2004(PHIPA). There is a regular schedule for environmental cleaning in the designated reprocessing area that includes a written policy and procedure and clearly defined responsibilities. 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. I have just received a request for copies of dental records from a denturist/independent dental hygienist. Keep accurate logs of all BI results in accordance with RCDSO record keeping requirements. Dentists are required to maintain patient confidentiality when disposing of dental records. What happens if the request for patient records comes from a family member of a deceased patient? 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. Border Patrol Sectors. 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. All Rights Reserved. Keep the register in a secure area in the office, preferably with the drugs. 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. Dentists are required by law to keep records. © Copyright 2021 Royal College of Dental Surgeons of Ontario. (10 years) Chemical Indicators (Class 5 Strips) A Class 5 is an indicator known as an 'Integrator' designed to react to all critical sterilization parameters (temp, pressure, time) Records for which the most recent entry was created on or after June 1, 2013 must be kept for 16 years from the date of last entry. Maintenance of a Learning Portfolio (Required for Option 1, Recommended for Options 2 and 3) Dental hygienists planning to submit their Quality Assurance information under Option 1 must maintain a Learning Portfolio and complete continuing quality improvement (CQI) activities that are sufficient to ensure What should I do? The province of Ontario has committed to implementing a comprehensive electronic health record for all Ontarians, and similar efforts are being made in other provinces and nations. 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. Keep it in a secure area in the office, preferably with the drugs, and reconcile it on a routine basis, depending on the nature of the practice and reasonable clinical judgement. Good record keeping is an important aspect for health and social care professionals. What financial records must be retained for patients? 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. The New Zealand Standard Health Records (NZS 8153:2002) sets out the minimum requirements for the appropriate documentation and management of health records within public and private That dentist should document the patient’s consent for this, as well as their subsequent return. Record Keeping Documentation of the sterilization of dental instruments and devices is a critical element of a dental practice’s IPAC program. Informed Compliance Publications. When a dental office is transitioning from paper records to electronic records, can existing paper records be scanned and destroyed? Keeping inadequate or inaccurate records is an act of professional misconduct at the Royal College of Dental Surgeons of Ontario (RCDSO). 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. In most cases, notification is required. Personnel recordkeeping regulations are found in . Health information custodians may also disclose personal health information to police without a warrant in limited circumstances outlined in PHIPA. Alternatively, the device may be physically destroyed. Regularly test your recovery procedures to ensure that all patient records and critical data can be retrieved and reliably restored from the backup copy. To allow for the provision of safe dental care, dentists must ensure that all necessary and relevant medical information is obtained prior to initiating treatment. Federal Register Notices. Cargo Security. Can a patient request copies of the dental records for his/her spouse and/or children? OTs must know and understand the record keeping requirements of their specific practice as responsibilities will vary depending on the role each OT assumes under PHIPA. When a dentist dies, what will happens to their patients’ dental records? • All … These regulations establish policies and minimum requirements governing the Protecting your health and your smile 175 Bloor St. E., North Tower, Suite 601, Toronto, ON M4W 3R8 t 416-961-6234 tf 1-800-268-2346 f 416-961-6028 Drug Register Dentists must maintain a drug register to record and account for all narcotics, controlled drugs and targeted substances that are kept on-site. The disposal of electronic patient records must be authorized by the dentist. The RCDSO has recently released new guidelines for dental offices to follow. How long do dentists have to keep dental records? In keeping and maintaining acceptable patient records, the following principles are essential: • All entries sh ould be dated and recorded by hand in permanent ink or typewritten, or be in an acceptable electronic format and “locked” on the date to which they are attributed. Describe the steps that you have taken to salvage or reconstruct the dental records and which records remain. Do dentists need to keep a drug register? While many dentists will provide copies of dental records at no charge as a courtesy to their patients, a dentist can charge a fee consistent with the direct costs incurred in duplicating and releasing them. 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. These financial records must be retained for at least ten years from the date of the last entry in that record. However, dentists can decide whether and how long to retain copies of other correspondence with insurance companies about dental insurance claims. 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. It is not considered appropriate to charge an administrative fee for the dental staff ’s time. Can a dentist e-mail a patient’s radiographs and other records to the patient or to another dentist? Preclearance. Alternatively, digital radiographic files can be saved and delivered on medium such as a CD-ROM or USB key. Do I have to provide them? Recall History Name: MR. / MISS / MRS. / MS. / DR. 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. eRuling Requirements. 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. 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. You may wish to notify the College, too. Legal Support for Victims of Sexual Abuse, List of Illegal/Unauthorized Practitioners, Sedation and/or General Anesthesia Inspection Program, COVID-19: Managing Infection Risks During In-Person Care, COVID-19 - Guidance for the Use of Teledentistry, Professional Patient-Dentist Relationships, Personal Health Information Protection Act, Practice Name Registration Application Form, Principles for Approved Sponsors and Core Course Presenters, Information on Change of Practice Ownership and Retiring, Information on New Practice Setup and Changing Practice Locations, Information on Prescribing and Dispensing Drugs, Post-Specialty Training Licence/Certificate, Registration Requirements for Int'l Applicants, Finance, Property and Administration Committee, Inquiries, Complaints and Reports Committee. Yes, if the patient has consented to the release of the records. 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. Who should I notify if patient records are damaged or destroyed? In most cases the patient’s new dentist will have provided a request for records signed by the patient. Protecting Agriculture. This interactive online course will discuss strategies to help improve recordkeeping and patient care in your dental office. If there are large volumes of paper records to sort and dispose of at one time, consider using a shredding or document management company. Border Security. Yes. If stored off-site, patient consent must be obtained. Do I have to release them? 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. If a patient and/or authorized representative requests a copy of the patient’s complete file this information must be provided. For example, this may include medical histories, examination findings, radiographs and other diagnostic records required to provide safe and appropriate dental care. There is increasing pressure on all health care professionals to convert from paper records to electronic records. Familiarize themselves with, and have a clear understanding of, the College’s standards of practice, guidelines, practice advisories and other publications Keep their clinical skills sharp and their knowledge base up-to-date through continuing education courses and review of … This information may be helpful should a claim or complaint arise at a later date. Can dentists store archived records off-site? 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. Customs Bulletin and Decisions. RCDSO, Standard of Practice Infection Prevention and Control in the Dental Office (2018) CDHO Infection Prevention and Control (IPAC) Guidelines (2018) M . Let’s Review the new RCDSO Guidelines Tuesday April 9th 2019 6:30-9PM-SOLD OUT Wednesday April 17th 2019 6:30-9PM-NEW DATE ADDED SOLD OUT Tues… In most cases, a parent can request and obtain copies of the dental records for children who are under the age of 16 years. Dentists are legally required to keep dental records. Health Information) Regulations 1996 set the minimum period for retention of patients’ records. Specific retention periods should take into account industry requirements and contractual obligations. 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. Profile (Reference (h)), and statutory requirements. My associate is leaving the practice and some of my patients are asking for their dental records to be released to the associate at his/her new practice location. 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. Dentists must protect the patient’s personal health information and should review the company’s privacy policy. 3.7 . Among other things, the Guidelines state that patient records must be accurate, comprehensive, legible and accessible. record retention guidelines for businesses & individuals This chart is a general guideline for the retention of many types of records. The Royal College of Dental Surgeons of Ontario (RCDSO) publishes Guidelines on Dental Recordkeeping, which includes a sample medical history questionnaire. This is a separate business issue that can be addressed according to the office’s collection policies and protocols. No. Yes. It is unacceptable to withhold the transfer of records because of an outstanding account balance. Toll Free: 800.565.4591 www.rcdso.org. These guidelines are designed to educate psychologists and provide a framework for making decisions regarding professional record keeping. The release and transfer of dental records should be accomplished within one to two weeks of receipt of the request. At Ports of Entry. 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. In PHIPA costs, charges from a damaged hard drive unacceptable to withhold the release of dental records to records... 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