Patient records, informed consent, confidentiality, and HIPAA-related obligations
Domain 5 - Patient records, informed consent, confidentiality, and HIPAA
This domain tests the documentation and privacy duties that attach to every encounter. Connecticut law and HIPAA operate together; where state law is stricter, the stricter rule controls.
Records
- The record must be contemporaneous, legible, and complete: history, examination findings, diagnosis, treatment, anesthesia, prescriptions, and instructions.
- Retain records for the period required by DPH regulations, and longer for minors; do not destroy records subject to a complaint or litigation hold.
- Patients are entitled to copies on request; a reasonable copying fee may be charged where permitted, but records cannot be withheld to collect an unpaid bill.
- Never alter a record after the fact. A late entry is dated and identified as late; erasures and backdating are discipline magnets.
Informed consent
- Consent must cover diagnosis, proposed treatment, material risks, alternatives (including no treatment), and likely outcome. Guarantees are improper.
- Written consent is expected for surgery, sedation, and other significant procedures; consent for a minor comes from a parent or legal guardian.
- Consent is a process, not a signature; document the discussion and the patient's questions.
Confidentiality and HIPAA
- Use and disclose protected health information only for treatment, payment, operations, or with a valid authorization, unless a legal exception applies.
- Exceptions include abuse and neglect reporting, certain public health disclosures, and court orders.
- Social media and before-and-after photographs require authorization; de-identification is harder than it looks.
Worked example
A patient asks for a full copy of her chart and mentions she is switching dentists. The office may charge the permitted copying fee but must provide the records promptly. It may not condition release on payment of the outstanding balance, and it should document the request. A summary is not a substitute unless the patient agrees.
Traps that cost marks
- Assuming HIPAA always preempts Connecticut law; it sets a floor.
- Discussing a patient in a public area or on social media.
- Relying on verbal consent for sedation.
- Rewriting a note after a bad outcome.