South Carolina § 40-15-450 - Patient records; health records.

§ 40-15-450. Patient records; health records.

(A) A dentist shall:

(1) maintain timely, legible, accurate, and complete patient records; and

(2) timely provide these records to the patient, another dentist, or a designated medical professional in response to a lawful request for the records by the patient or his legal representative or designee.

(B) A dental practice must have a procedure for initiating and maintaining a health record for every patient evaluated or treated. For procedures requiring patient consent, there must be an informed consent documented in the patient record.

(C) The health record of a patient required under subsection (B) must include appropriate information to:

(1) identify the patient, support the diagnosis, and justify the treatment;

(2) identify the procedure code or suitable narrative description of the procedure; and

(3) document the outcome and required follow-up care.

(D) If moderate sedation or deep sedation/general anesthesia is provided, the health record of a patient also must include documentation of:

(1) patient weight;

(2) type of anesthesia used;

(3) type and dosage of drugs administered, if any;

(4) fluid administered, if any;

(5) a record of vital signs monitoring;

(6) patient level of consciousness during the procedure;

(7) duration of the procedure;

(8) complications related to the procedure or anesthesia, if any; and

(9) time-oriented anesthesia record.

HISTORY: 2014 Act No. 222 (S.1036), SECTION 2, eff January 1, 2015.