Patient Records, Confidentiality, and Informed Consent
Records as a professional duty
Candidates should understand that patient records must be created, maintained, and retained in accordance with law and Board rule, and that records belong to the practice while patients have rights of access. Traps include assuming records can be destroyed at will or withheld to collect a fee; access rules generally do not permit using records as leverage.
Confidentiality and its limits
Confidentiality protects patient information, but disclosure is permitted or required in defined situations: patient authorization, legal compulsion, certain public health reporting, and emergencies. Questions test whether a disclosure fits an exception. The trap is treating confidentiality as absolute.
Informed consent
Informed consent requires disclosure of the nature of the procedure, material risks, benefits, and alternatives, and the patient's voluntary agreement. Consent should be documented. Traps include assuming a signed form alone satisfies consent if the discussion did not occur, and overlooking consent for nontrivial interventions such as contact lens wear or therapeutic prescribing.
Worked example / rule of thumb
A patient requests a copy of the record. The correct analysis: provide access per the applicable rule, applying any permitted fee for copies, without conditioning on payment of an unrelated balance. Rule of thumb: document consent, protect information, and disclose only through a recognized exception.