Patient Records, Informed Consent, and Confidentiality
Patient records must be accurate, complete, and maintained for a specified period (typically 5 years from last treatment, but verify). Records include patient history, diagnoses, treatment plans, progress notes, radiographs, and informed consent documentation. Informed consent requires that the patient be informed of the diagnosis, proposed treatment, risks, benefits, alternatives, and consequences of no treatment, and must voluntarily agree. Consent can be verbal or written, but written is preferred for invasive procedures. Minors require parental consent. Confidentiality means protecting patient information; disclosure without consent is only allowed for treatment, payment, or healthcare operations, or as required by law (e.g., reporting abuse, court order). Traps include assuming that records can be destroyed immediately after treatment, or that consent is implied for all procedures. Rule of thumb: if it's not documented, it didn't happen. Example: A dentist must obtain informed consent before extracting a tooth, and document the discussion. Another trap is discussing patient information in public areas; this is a HIPAA violation and unprofessional conduct. The Board may discipline licensees for failing to keep adequate records or breaching confidentiality. Patients have a right to access their records, and a dentist may charge a reasonable fee for copies. Records must be kept for the period required by Board rules; destruction must be done securely. Candidates should know that informed consent is an ongoing process, not just a signature. Also, electronic records must be secure. Always verify the current record retention requirement. Understanding these principles ensures compliance and patient trust.