HIPAA and the dental record: Dental assisting

The dental record is a legal and clinical document that supports patient care, communication, and legal protection. Often called the patient chart, it provides an account of what transpired during treatment and documents the patient’s longitudinal history of dental care.

As a dental assistant, you’ll provide high-quality patient care by accurately documenting the details of patient care into the dental record while safeguarding your patient’s private medical and dental information.

Now, the content of your patient’s dental record is protected under the Health Information Portability and Privacy Act, or HIPAA, which is the US federal law that establishes rules for keeping patient information private and safe. HIPAA defines what is considered protected health information, or PHI, and how it can be communicated, recorded, and shared. In a dental record, PHI can include a patient’s name, date of birth, phone number, address, and health insurance information, as well as health history, diagnoses, treatments, test results, and prescription information.

HIPAA also requires electronic PHI to be encrypted, and computer firewalls to be in place, while any paper records must be securely locked; and all dental staff who have access to PHI must complete security awareness training about their responsibilities to protect the confidentiality and integrity of PHI. Lastly, there must be a written privacy policy that informs patients that their PHI will not be used or disclosed for any purpose other than for treatment, diagnosis, and billing. Every patient needs to review and sign a form to acknowledge that they’re aware of these privacy practices.

So, now that you understand the importance of keeping your patient’s PHI safe, let’s talk about the legally permitted uses and disclosures of your patient’s PHI. First, you’ll primarily use your patient’s dental record during patient care, which can include reviewing your patient’s health history to identify conditions or medications that could affect treatment; taking notes during a procedure; creating treatment plans; storing images like X-rays or intraoral photographs; and scheduling appointments. The dental record can also be shared with other dental professionals to coordinate care. For example, when a patient needs to be referred to specialty care, like oral surgery. Dental records can also be used for certain quality assurance activities, like chart audits to ensure standards of care and documentation are being followed or to review treatment outcomes. PHI is also used for financial uses such as billing insurance companies and processing payments for treatments.

Next, let’s look at the components of the dental record, each of which may contain patient PHI. The patient registration section includes information from the registration and intake form filled out by the patient before establishing care with the dental practice, and includes patient demographics and financial responsibilities, including insurance and billing information.

The patient will also provide information on their medical and dental history including chronic health conditions, allergies, and current medications, as well as surgical and past dental care. These details alert the dental team to any issues that could complicate or interfere with dental care and anticipate potential medical emergencies that could occur during treatment. This information needs to be updated, as needed, at every visit.