Patient records, confidentiality, and informed consent
Patient records, confidentiality, and informed consent
This domain tests the administrative side of practice: what a record must contain, who owns and may see it, how long it is kept, and how consent is obtained and documented.
Required content
Every record should show patient identification, medical and dental history, clinical findings, diagnosis, treatment plan, informed consent, radiographs with dates, anesthesia used, medications prescribed, progress notes with dates and the provider for each entry, and relevant communications. Entries must be contemporaneous, legible, and permanent. Altering a record after a complaint is a separate disciplinary offense.
Ownership and access
The practice owns the physical record; the patient has a right of access to the information in it. On a valid written authorization, copies must be provided within the time the law allows, and a reasonable copying fee may be charged. Refusing to release records because of an unpaid balance is a classic violation, as is releasing them to a family member, employer, or another dentist without authorization. Exceptions include statutory abuse reporting, court orders, and public-health requirements.
Retention
The Board's rule sets the minimum retention period; keep records at least that long from the last treatment and, for minors, until the patient reaches majority plus the retention period. Retention obligations survive practice sale, retirement, or the dentist's death - the records pass to a custodian, never to the shredder.
Informed consent
Consent is a process, not a signature. Explain the diagnosis, proposed treatment, material risks, alternatives including no treatment, and the likely consequences of declining; document the discussion and the patient's agreement. Minors require a parent or guardian's consent except in the narrow emergency circumstances the law recognizes. Consent to photography or publication is separate from consent to treatment.
Worked example
A patient requests her chart because she is transferring to a new dentist, and the front office refuses until the balance is paid. Wrong: access turns on a written request and a permissible fee, not on payment of the bill. Provide the copies and pursue the debt separately.
Traps
- Backdating or "cleaning up" notes after an adverse event.
- Assuming HIPAA alone answers the question - Georgia access rules apply too.
- Relying on a generic signed form with no documented discussion.
- Discussing a patient's care in a public area or with an unauthorized family member.