Patient Records, Informed Consent, Confidentiality, and Mandatory Reporting
This domain blends clinical ethics with statutory duties. Candidates must know the content, retention, access, and release rules for patient records, plus the boundaries of consent and confidentiality.
Records
A compliant record is contemporaneous, legible, identifies the provider and patient, documents history, examination, diagnosis, treatment plan, informed consent, and progress. Know retention periods and the rule that records belong to the practice/chiropractor while patients have a right of access to their own records. Traps: releasing records without proper authorization, altering records after a complaint, and failing to document informed consent.
Informed consent
Consent must be informed: diagnosis, nature and purpose of treatment, risks and benefits, alternatives (including no treatment), and the opportunity to ask questions. It may be written or oral depending on the rule, but documentation is the safest practice. Special rules may apply to minors and incapacitated adults.
Confidentiality and reporting
Confidentiality is broad but not absolute. Know the mandatory reporting duties: suspected child abuse or neglect, and other reportable conditions as defined by statute. Reporting in good faith is protected; failure to report is itself a violation. Also understand that public health reporting and court orders can override confidentiality.
Rule of thumb: When a question asks whether to release records, ask: Is there patient authorization, a legal requirement, or a court order? If none, do not release.
Example: A parent requests a minor's records - generally permissible for the legal guardian, but be alert to custody orders limiting access.