Patient Records, Informed Consent, and Confidentiality
Patient records are both a clinical and a legal document. Candidates should understand that records must be accurate, legible, contemporaneous, and complete, documenting assessment, treatment, patient responses, and communications. Records belong to the practice, but patients have rights of access consistent with state law and HIPAA. Retention requirements and secure disposal are governed by statute and rule.
Informed consent requires disclosure of the nature of the procedure, risks, benefits, alternatives, and the consequences of declining, followed by the patient's voluntary authorization. Traps include assuming a signed form alone proves informed consent - the discussion matters. Another trap is treating consent for one procedure as covering another, or allowing a blanket consent to substitute for procedure-specific discussion. Consent for minors generally requires a parent or legal guardian.
Confidentiality protects patient information from unauthorized disclosure. Permitted disclosures include treatment, payment, operations, mandated reporting, and legal compulsion. Minimum necessary disclosure is the guiding principle. Altering records after the fact, or making late entries without identifying them as late, undermines credibility and may constitute unprofessional conduct.
Rule of thumb: if it is not documented, it is hard to prove it happened; document the consent conversation, not just the signature.
Worked example: A hygienist discusses a patient's condition with a friend who is also a patient of the practice. Even though both are patients, this is an unauthorized disclosure and a confidentiality violation.