Part III. Standards of Conduct
18VAC60-25-110. Patient records; confidentiality.
A. A dental hygienist shall be responsible for accurate and complete information in patient records for those services provided by a hygienist or a dental assistant under direction to include the following:
1. Patient's name on each page in the patient record;
2. A health history taken and documented at the initial appointment, which is updated when local anesthesia or nitrous oxide/inhalation analgesia is to be administered and when medically indicated and at least annually;
3. Options discussed and documented written consent in the patient record for any treatment rendered with the exception of prophylaxis;
4. List of drugs administered and the route of administration, quantity, dose, and strength;
5. Radiographs, digital images, and photographs clearly labeled with the patient's name, date taken, and teeth identified;
6. A notation or documentation of an order required for treatment of a patient by a dental hygienist practicing under general supervision as required in 18VAC60-25-60 C; and
7. Notation of each treatment rendered, date of treatment, and the identity of the dentist and the dental hygienist providing service.
B. No dental hygienist shall willfully or negligently breach the confidentiality between a practitioner and a patient. A breach of confidentiality that is required or permitted by applicable law or beyond the control of the hygienist shall not be considered negligent or willful.
C. A dental hygienist practicing under remote supervision shall document in the patient record that the dental hygienist has obtained (i) the patient's or the patient's legal representative's signature on a statement disclosing that the delivery of dental hygiene services under remote supervision is not a substitute for the need for regular dental examinations by a dentist and (ii) verbal confirmation from the patient that the patient does not have a dentist of record whom the patient is seeing regularly.
Statutory Authority
§ 54.1-2400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 5, eff. December 2, 2015; amended, Virginia Register Volume 33, Issue 4, eff. November 16, 2016; Volume 34, Issue 1, eff. October 4, 2017; Volume 41, Issue 2, eff. October 24, 2024.
18VAC60-25-120. Acts constituting unprofessional conduct.
The following practices shall constitute unprofessional conduct within the meaning of § 54.1-2706 of the Code of Virginia:
1. Misrepresenting to a patient and the public the materials or methods and techniques the licensee uses or intends to use.
2. Delegating any service or operation that requires the professional competence of a dentist or dental hygienist to any person who is not a licensee or registrant as authorized by this chapter.
3. Violating or cooperating with others in violating provisions of Chapter 1 (§ 54.1-100 et seq.) or 24 (§ 54.1-2400 et seq.) of Title 54.1 of the Code of Virginia or the Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia).
Statutory Authority
§ 54.1-2400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 5, eff. December 2, 2015; amended, Virginia Register Volume 41, Issue 2, eff. October 24, 2024.