Patient Records, Informed Consent, and Confidentiality
Records, consent, and confidentiality are the legal memory of the patient relationship. Records must be contemporaneous, legible, accurate, and complete enough for another clinician to continue care. Know what must be documented: history, examination findings, diagnosis, treatment plan, informed consent discussions, anesthesia used, medications, radiographs with interpretation, referrals, and any refusal of treatment. Corrections must be made without obliterating the original entry - a late entry is dated and identified as such; erasure or backdating is a disciplinary problem, not a clerical one.
Informed consent requires disclosure of the nature of the procedure, material risks and benefits, alternatives including no treatment, and the opportunity to ask questions, given by a person with capacity and free of coercion. Know who may consent for a minor or an incapacitated adult, and that consent for a specific procedure does not authorize unrelated treatment. Consent should be documented, and the discussion - not just the signature - is the operative legal element.
Confidentiality is limited: disclosures may be permitted or required for treatment, payment, operations, public health reporting, suspected abuse, court orders, and with valid authorization. Release to a third party generally requires a compliant authorization, and minimum necessary disclosure is the default posture.
Traps: assuming a signed form cures an inadequate consent discussion; altering a record without notation; and treating all disclosures as prohibited.
Rule of thumb: if it is not in the record, it did not happen; if you change the record, say so in the record.