Patient Records, Informed Consent, and Confidentiality
Core concepts
Understand the duty to create and maintain accurate patient records, the required contents (history, examination findings, diagnosis, treatment plan, progress notes), retention periods, and the rules for releasing records. Know the elements of informed consent: diagnosis, nature and purpose of proposed care, risks and benefits, alternatives (including no treatment), and the patient's right to withdraw consent. Understand confidentiality and the exceptions permitting or requiring disclosure (patient authorization, subpoena, abuse reporting, public health requirements).
Traps in questions
- Assuming verbal consent is always sufficient; significant or invasive procedures may require written consent.
- Forgetting that informed consent is an ongoing process, not a one-time signature.
- Overlooking that records belong to the provider but patients have a right of access.
- Missing mandatory reporting exceptions (e.g., suspected abuse) that override confidentiality.
- Confusing retention requirements with the patient's right to obtain copies.
Rule of thumb
For consent questions, use the mnemonic DRAW: Diagnosis, Risks, Alternatives, and Withdrawal/right to refuse. For record questions, ask whether the record is accurate, contemporaneous, retained, and released only with proper authorization or legal compulsion.
Worked example
A patient requests copies of records; the provider may charge a permitted fee but cannot refuse access merely because a bill is unpaid, absent a specific statutory allowance. Exam answers should reflect the patient's statutory access right.