Patient Records, Informed Consent, and Confidentiality
What this domain tests
This domain tests documentation standards, record retention and release, the elements of a valid informed consent, and the confidentiality duties that run alongside HIPAA.
Record standards
- Contemporaneous, legible, signed and dated entries; the author is identifiable.
- A medical history that is updated, not just signed once at the first visit.
- Radiographs, charting, consent forms, referrals, and communication with the patient all belong in the record.
- Corrections are made with a single line, initial, and date so the original entry stays readable. Never obliterate, backdate, or rewrite an entry.
Ownership, retention, and release
The practice owns the original record; the patient is entitled to a copy, generally on written authorization and subject to any permitted copying fee. Board rules set the retention period, and records of minors must survive until the retention period runs after the age of majority. Records transfer to a successor practice or are handled according to the Board's rule when a practice closes.
Informed consent
Valid consent requires a competent patient or authorized representative, disclosure of the diagnosis, the nature and purpose of the proposed treatment, material risks and benefits, alternatives including no treatment, and a voluntary decision. Consent for a minor comes from the parent or legal guardian. Refusal of treatment is documented with the same care as consent.
Confidentiality
Protected health information may be disclosed for treatment, payment, and operations, or with a valid authorization. Subpoenas are not automatic permission slips; verify the legal basis. Georgia law also provides specific protections for certain information, such as HIV status, which require stricter handling than the general rule. Public health reporting is a recognized exception.
Worked example
A crown fails and the patient complains. The dentist adds a note dated three months earlier saying "patient noncompliant with hygiene." That is fabrication. It is a disciplinary matter, it is discoverable, and it invites an inference that the true record was unfavorable.
Traps
- Telling a patient the original chart belongs to them.
- Assuming HIPAA alone answers every disclosure question.
- Certifying a consent form the patient never discussed.