Okla. Stat. tit. 59, § 59-328.31b: Patient record keeping requirements

A. Every dental office or treatment facility, whether

individual, group or multi-doctor practice operating under a name,

trade name or other professional entity shall maintain written

records on each patient treated at the facility and shall make these

records available to the Board of Dentistry and other regulatory

entities or be subject to the penalties as set forth in Section

328.44a of this title.

B. Each licensed dentist shall maintain written records on each

patient that shall contain, at a minimum, the following information

about the patient:

1. A current health history listing known illnesses, other

treating physicians and current medications prescribed;

2. Results of a clinical examination, including a physical

intraoral examination and head and neck examination, tests

conducted, and any lab results including the identification, or lack

thereof, of any oral pathology or diseases;

3. Treatment plan proposed by the dentist; and

4. Treatment rendered to the patient. The patient record shall

clearly identify the dentist and the dental hygienist or dental

assistant providing the treatment with the dentist, specialty or

dental hygienist license number. The patient record shall include

documentation of any medications prescribed, administered or

dispensed to the patient.

C. Prior to a dentist prescribing, diagnosing, or overseeing

patient treatment for any dental appliance, the patient shall be a

patient of record and the dentist shall conduct an in-person patient

examination.

D. 1. The name of the dentist or dentists actually providing

the dental services to the patient shall appear on all insurance

claim forms, billing invoices, or statements sent to the patient and

on all receipts if any are given to the patient.

2. Treatment records shall be maintained for each patient that

clearly identify the dentist or dentists who performed all dental

services for the patient.

E. Whenever patient records are released or transferred, the

dentist releasing or transferring the records shall maintain either

the original records or copies thereof and a notation shall be made

in the retained records indicating to whom the records were released

or transferred.

F. All claims being submitted for insurance must be signed,

stamped or have an electronic signature by the treating dentist.

G. Patient records may be kept in an electronic data format,

provided that the dentist maintains a backup copy of information

stored in the data processing system using disk, tape or other

electronic back-up system and that backup is updated on a regular

basis, at least weekly, to assure that data is not lost due to

system failure. Any electronic data system shall be capable of

producing a hard copy on demand.

H. All patient records shall be maintained for seven (7) years

from the date of treatment.

I. Each licensed dentist shall retain a copy of each entry in

his or her patient appointment book or such other log, calendar,

book, file or computer data used in lieu of an appointment book for

a period no less than seven (7) years from the date of each entry

thereon.

J. A licensee closing an office shall notify the Board in

writing and include the location of where the patient records will

be maintained.