(1) A dental hygienist who treats patients shall maintain legible, complete, and accurate patient records.

(2) The patient record must contain the clinical records and the financial records.

(3) The clinical record must include at least the following information for each entry:

(a) The signature, initials, or electronic verification of the individual making the entry note;

(b) The identity of who provided treatment if treatment was provided;

(c) The date of each patient record entry;

(d) The physical examination findings documented by subjective complaints, objective findings, an assessment of the patient's condition, and plan;

(e) A dental hygiene treatment plan based on the analysis of assessment findings;

(f) Up-to-date dental hygiene and medical history that may affect dental hygiene treatment;

(g) A complete description of all treatment/procedures administered at each visit;

(h) An accurate record of any medication(s) administered;

(i) Referrals and any communication to and from any health care provider;

(j) Notation of communication to or from the patient or minor patient's parent or guardian, including:

(i) Notation of the informed consent discussion. This is a discussion of potential risk(s) and benefit(s) of proposed treatment, and alternatives to treatment, including no treatment;

(ii) Notation of posttreatment instructions or reference to an instruction pamphlet given to the patient;

(iii) Notation regarding patient complaints or concerns associated with treatment, this includes complaints or concerns obtained in person, by phone call, email, mail, or text; and

(iv) Termination of hygienist-patient relationship.

(4) Clinical record entries must not be erased or deleted from the record.

(a) Mistaken handwritten entries must be corrected with a single line drawn through the incorrect information. New or corrected information must be initialed and dated.

(b) If the record is an electronic record then a record audit trail must be maintained with the record that includes a time and date, history of deletions, and edits and corrections to the electronically signed records.