Patient Records, Confidentiality, and Informed Consent
Records as a professional duty
The patient record is the optometrist's contemporaneous account of care and belongs to the practice, while the patient has a right of access to the information. Records must be legible, dated, authenticated, and sufficiently detailed to allow another practitioner to understand the care. Retention must satisfy both Board rules and applicable law, and records must be released on proper patient authorization or as required by law.
Confidentiality and its exceptions
Confidentiality is a core ethical and legal duty. Disclosure requires patient authorization, with recognized exceptions: legal compulsion (subpoena or court order), public health reporting, emergency situations, and certain peer review or quality-assurance contexts. A subpoena is not automatically a license to disclose everything - the practitioner should verify validity and scope and may need patient notice or a protective order.
Informed consent
Informed consent requires disclosure of the nature of the proposed care, material risks, benefits, alternatives (including no treatment), and the opportunity to ask questions, followed by the patient's voluntary agreement. Consent for routine care may be implied; invasive or higher-risk procedures and research require explicit documented consent.
Traps
- Releasing records on a subpoena without checking validity or scope.
- Assuming records belong to the patient - access rights differ from ownership.
- Treating a signed form as a substitute for an actual informed-consent discussion.
Rule of thumb
For any disclosure question, apply the four-part test: authorization, legal compulsion, public health duty, or emergency. If none applies, do not disclose.