Patient records, informed consent, and confidentiality
This domain tests the legal life of clinical information: what must be recorded, how long it is kept, when it may be released, and how consent is obtained. Connecticut law, HIPAA, and professional standards overlap. The exam favors concrete scenarios involving minors, unpaid bills, corrections, and unauthorized disclosures.
Records
- Maintain accurate, contemporaneous, legible records of assessments, treatment, medications, referrals, and patient instructions.
- Do not alter a record to hide an error. Correct with a dated addendum that identifies the author and preserves the original entry.
- Connecticut dental record rules require retention for a defined period, commonly at least seven years from the last treatment, with longer retention for minors. Verify the current rule before destroying records.
- Release records only with patient authorization or as required or permitted by law; charge only allowed fees.
Informed consent
- Consent must be informed: diagnosis or condition, proposed treatment, material risks, alternatives, and consequences of no treatment.
- Obtain consent from the patient or the legally authorized representative; for minors, generally a parent or guardian, subject to specific adolescent confidentiality rules.
- Emergency treatment may proceed when delay would endanger the patient, with documentation.
Worked example
A patient with an unpaid balance asks for a copy of her records. The office refuses until payment. The better answer is that the bill does not erase the patient's access rights; the practice should follow Connecticut and HIPAA access rules, charge only permitted fees, and release the records through the authorized process. Withholding records solely to collect a debt creates legal risk.
Traps that cost marks
- Disclosing HIV, mental health, or substance-use information without the extra authorization required by law.
- Discussing a patient in a public hallway or on social media.
- Letting a parent see records that Connecticut law treats as confidential adolescent care without checking the specific rule.
- Backdating a record or destroying the original entry.
- Assuming HIPAA alone answers every Connecticut confidentiality question.
Exam focus
Identify the requester's legal authority, the sensitivity of the information, and the required authorization. When records and consent conflict, follow the statute and get legal guidance rather than office habit.