Patient Records, Informed Consent, and Confidentiality
Records
Arizona licensees must maintain legible, accurate, and timely records for each patient, sufficient to justify the diagnosis and treatment. Records should include the medical and dental history, clinical findings, radiographs, treatment rendered, medications prescribed, and informed consent documentation. Retention rules require records be kept for the period specified by Board rule, and records must be produced to the Board on lawful request. Traps include items suggesting records may be altered after a complaint, or that a licensee may withhold records from a patient who requests them.
Informed consent
Consent must be informed: the patient should understand the diagnosis, the nature and purpose of the proposed treatment, the material risks and benefits, reasonable alternatives including no treatment, and the likely consequences of declining. Consent for minors and for patients unable to consent follows statutory rules on who may consent. A signed form alone does not establish informed consent if the discussion did not occur.
Confidentiality
Patient information is confidential and may be disclosed only with authorization or as required or permitted by law (for example, mandatory reporting, court order, or treatment coordination). Traps include discussing a patient in a public area, disclosing to a family member without authority, and assuming that a subpoena automatically permits disclosure of the entire record.
Rule of thumb
For consent items, ask whether the patient was told the risks, the alternatives, and the consequences of refusal. For confidentiality items, ask whether there is an authorization or a legal mandate.
Worked example
An item describes a signed consent form obtained without any discussion of alternatives. The form does not cure the absence of informed consent; the correct answer identifies a failure of the consent process.