What's Included in Dental Records and How Can You Access Yours?

Man Reading Dental Records at Home

At your last dental checkup, did you notice your dentist or dental hygienist typing rapidly on the computer or writing in a dental chart as you discussed your oral health? It's important to understand what's included in your dental records and how to access them. Here's what to know.

What Does a Dental Record Include?

Dental records, also known as patient charts, are made up of the recorded information regarding your medical history, diagnostic information, clinical notes, patient-doctor communication, consent to treatment documents and treatment notes, as the American Dental Association (ADA) explains. They also include personal contact information, such as your name, address, phone number and employment information. A typical health history form you fill out at the dental office gathers information about specific health concerns, such as heart disease, drug use and pregnancy. This way, your dental team is informed if you have any health issues that could potentially impact your dental care. This document and others will need to be updated regularly to account for any health changes you experience.

Why You Would Need Access to Your Dental Records?

The ADA notes that dental charts are legal documents owned by the dental office. However, there are instances where you may want direct access to your dental records. If you are changing dental providers, your old provider will need to transfer your record to your new dentist. Or, if you are having a medical procedure done, the medical doctor may require your dental information. According to the ADA, you can request your dental records in the case of allegations of malpractice or to help authorities identify a deceased person. You may also simply want a copy to make sure that you fully understand and have record of your dental care.

How to Access Your Patient Chart?

Because the dental office owns the record, you do not have the right to obtain your original file, as the ADA explains. However, you can request a copy. Depending on your state of residence, there are slight differences in how to request the record, what fees you might need to pay and how long the dental office has to release the copy to you.

For example, according to the Washington State Legislature, in the state of Washington, dentists must release the copied records within 15 business days of receiving a written request. In most cases, you must make a written request in order to obtain a copy of your patient chart. Some dental offices may have a request form or require you to sign for the file when you get it. To find out, call your dentist and ask what the request procedure entails. Even if you are no longer an active patient, your old dental office is required to retain your record for several years. Depending on the state, the retention time can vary. In Washington, dentists are required to hold records for six years after the last appointment.

Dental records are an important part of your medical history. You may find yourself needing a copy of your chart for personal or legal reasons. If and when you need a copy, make sure to contact your dental office and ask how the process works. The directions should be easy to follow, and your dental office team will be happy to help.

This article is intended to promote understanding of and knowledge about general oral health topics. It is not intended to be a substitute for professional advice, diagnosis or treatment. Always seek the advice of your dentist or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment.

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What To Expect During a DENTAL VISIT

On your first visit, your dentist will take a full health history. On follow-up visits, if your health status has changed, make sure to tell your dentist. Here’s what you can expect during most trips to the dentist.

  • A Thorough Cleaning – a dental hygienist or dentist will scrape along and below the gum line to remove built-up plaque and tartar that can cause gum disease, cavities, bad breath and other problems. Then he or she will polish and floss your teeth.

  • A Full Dental Examination – your dentist will perform a thorough examination of your teeth, gums and mouth, looking for signs of disease or other problems.

  • X-Rays – X-rays can diagnose problems otherwise unnoticed, such as damage to jawbones, impacted teeth, abscesses, cysts or tumors, and decay between the teeth.