Patient Records, Informed Consent, and Confidentiality
Domain 5 asks who owns the record, who may see it, how consent is documented, and what to do when a demand letter or subpoena arrives.
Ownership and patient access (s. 456.057)
The record is the property of the practice, but the patient or the patient's legal representative has a statutory right to copies. Charges are capped by statute - a per-page tier for paper copies plus the actual cost of reproducing radiographs - and records should not be withheld as leverage in a billing dispute. A provider may release records without authorization to another health care practitioner for continuing care, and to the department during an investigation.
Content and retention
Records must be legible, contemporaneous, identified by patient, and signed and dated with credentials. Include chief complaint, history, examination findings, diagnosis, treatment plan, modality parameters, response, referrals, and the consent discussion. Retention follows board rule; treat four years from the last professional service as the floor, and never destroy records that are the subject of a complaint, claim, or litigation. Correct errors with a dated addendum; never alter an original entry.
Informed consent
Consent must cover the material risks of the proposed care - including the recognized though rare risk of vertebral artery injury with cervical manipulation - the alternatives, and the consequences of declining. Document the discussion and keep the signed form; s. 766.103 supplies the standard for what a reasonable practitioner would disclose.
Worked example
An attorney sends a subpoena for a patient's file with no authorization attached. Reasoning: a subpoena is not a court order and does not by itself waive confidentiality. Do not release; notify the patient or the patient's counsel and require a signed authorization or an order, then document the request and the response. Releasing on the subpoena alone is the classic confidentiality violation.
Traps
- Treating a subpoena as judicial authorization.
- Assuming HIPAA lets you refuse the patient a copy; it gives the patient a right of access.
- Relying on an undocumented verbal consent.