On August 22, 2014, the Florida Board of Dentistry will meet to discuss implementing new requirements for record keeping. We believe that these changes are due to the Board’s concern over potential ambiguity with the current regulations, and due to the recent difficulty it had in disciplining Florida dentists for record keeping violations.
Read on for an outline of the proposed new requirements. Be sure to check this blog regularly. We will have a firm representative at this meeting and will post any updates.
Current Florida Rule.
Rule 64B5-17.002, Florida Administrative Code, provides the minimum record keeping requirements placed on Florida’s dentists. Currently, the rule requires a dentist to record the following information:
(a) Appropriate medical history;
(b) Results of clinical examination and tests conducted, including the identification, or lack thereof, of any oral pathology or diseases;
(c) Any radiographs used for the diagnosis or treatment of the patient;
(d) Treatment plan proposed by the dentist; and
(e) Treatment rendered to the patient.
Outline of Proposed New Requirements.
The proposed rule change will amend the Rule 64B5-17.002, Florida Administrative Code, as follows:
(a) Appropriate medical history, including any current or previous medical conditions, surgeries, hospitalizations, medications, and legible blood pressure readings (when taken). The updating and review of the medical history must also be documented.
(b) Results of clinical examinations and tests conducted, including the identification, or lack thereof, of any oral pathology or diseases.
(c) Any radiographs to include Cone Beam Computer Tomography (CBCT), and the results used for the diagnosis or treatment of the patient.
(d) Treatment plan and treatment options proposed by the dentist.
(e) Treatment rendered to the patient, including but not limited to the following, when applicable to the treatment performed:
(i) Type, amount, and mode of delivery (i.e., Mandibular block, Infiltration, etc.) of local anesthesia used;
(ii) Type and shade of restorative material used;
(iii) Preoperative and/or postoperative medications prescribed;
(iv) Medications delivered, administered, or provided to the patient during treatment or for use following treatment;
(v) Radiographs taken;
(vi) Impression material and type of impression taken (i.e., maxillary, mandibular, interocclusal, digital, etc.);
(vii) Medicaments, medications, sutures, irrigants, or bases applied to teeth or periodontal tissues;
(viii) Names or initials of all staff involved with clinical care of the patient;
(ix) Use of dental barrier or rubber dam;
(x) Tooth or arch treated identified by name, number or letter;
(xi) Working length, canals treated, identify untreated canals and reason left untreated, master apical file size, and obturation materials used during endodontic procedures; and
(xii) Unusual or unexpected events or reactions during or after the procedure including, but not limited to separation, breakage, retention, swallowing or aspiration, of any instrument or portion thereof.
In addition to the above changes, the Board is also seeking a number of other amendments to the rule, including additional requirements for record alterations and duties of dentists of record.
The complete proposed rule change can be found at: http://bit.ly/1vr4Cxw
Did you know about these proposed changes? If imposed, how will the changes affect you? Please leave any thoughtful comments below.
Consult With An Attorney Experienced in the Representation of Dentists.
We routinely provide deposition coverage to dentists, dental hygienists and other health professionals being deposed in criminal cases, negligence cases, civil cases or disciplinary cases involving other health professionals.
The lawyers of The Health Law Firm are experienced in both formal and informal administrative hearings and in representing dentists and dental hygienists and other health professionals in investigations and at Board of Dentistry hearings. Call now or visit our website www.TheHealthLawFirm.com.
About the Author: Christopher E. Brown, J.D., is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
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