Patient Rights, Informed Consent, Confidentiality, and Recordkeeping/Documentation
What this domain tests
This domain tests the patient-facing duties of a California PT: obtaining informed consent, protecting confidentiality, and maintaining records that meet legal and professional standards. Items often present a documentation or privacy scenario and ask what the licensee should have done.
Core rules
- Informed consent: the patient must receive information about the proposed treatment, its risks and benefits, and reasonable alternatives, and must agree to proceed. Consent must be voluntary and obtained from a patient with capacity; for minors or patients lacking capacity, consent comes from a legally authorized representative. Consent should be documented.
- Confidentiality: patient information is protected. Disclosure requires patient authorization or a legal exception such as a court order, mandated reporting, or a public health requirement. Casual discussion of patients in public areas is a violation.
- Records: the PT must maintain accurate, timely, and legible records that reflect the examination, evaluation, plan of care, treatment provided, the patient's response, and discharge. Records must be retained for the period required by law and made available as required.
- Corrections: errors in a record are corrected with a dated, signed addendum or a single line through the error with initials and date; records are not altered or destroyed to conceal events.
- Access: patients have rights to access their records consistent with law, and the licensee must respond appropriately to requests.
Worked example
A patient asks to see her chart. The PT says she will "summarize it verbally" instead of providing copies. Is that sufficient?
Reasoning: patient access is a legal right, not a courtesy. A verbal summary does not satisfy an access request unless the patient agrees to that format or a legal exception applies. The PT should follow the applicable access process, provide the records or a permitted summary, and document the request and response. Answer: no; the verbal summary alone does not discharge the access obligation.
Traps that cost marks
- Treating a signed general intake form as informed consent for every later procedure.
- Discussing a patient's case in an elevator or waiting room; confidentiality applies everywhere.
- "Fixing" a record by erasing or rewriting the original entry.
- Assuming a minor can consent to their own physical therapy without a representative.
Key points
- Informed consent requires risks, benefits, alternatives, and voluntary agreement, documented.
- Minors and incapacitated patients require consent from a legally authorized representative.
- Confidentiality yields only to authorization or a legal exception.
- Records must be accurate, timely, and retained as required.
- Correct errors by addendum or initialed single line, never by alteration.