Recordkeeping, Informed Consent, and Patient Protection
This domain tests the paper trail and patient-protection duties: what must be in the record, how long to keep it, when consent is valid, and how to protect patients from harm and exploitation.
Records
- Create a contemporaneous, legible record for every encounter: identity, date, history, examination findings, diagnosis, treatment, response, and instructions.
- Document informed consent discussions, refusals, and referrals.
- Retain records under Hawaii's health-care records retention law, HRS §622-58, and Board rules; the usual benchmark is seven years after the last treatment, with longer retention for minors. Release records only with a valid authorization or as required by law; follow HIPAA where applicable.
- Never alter a record after a complaint; make a late entry clearly dated and identified.
Informed consent
- Obtain consent before care: diagnosis, nature of the proposed care, material risks and benefits, alternatives (including no treatment), and likely consequences of refusal.
- Document the discussion and the patient's decision. For minors, obtain parent or guardian consent unless a specific statute allows the minor to consent.
- Consent must be voluntary and can be withdrawn.
Patient protection
- Maintain confidentiality; report suspected child abuse under HRS chapter 350 and elder abuse under HRS chapter 346 as required.
- Use infection control; do not treat beyond competence; terminate care properly to avoid abandonment.
- Keep boundaries and avoid dual relationships that impair judgment.
Worked example
A patient refuses lumbar x-rays after a fall with red-flag symptoms. The chiropractor explains the risk, offers referral, and documents the refusal and the patient's decision to proceed only with conservative care. Analysis: the record shows informed refusal, not abandonment. If the patient later claims lack of consent, the contemporaneous note is the best evidence. If the chiropractor had simply adjusted without documenting the discussion, the Board could treat it as a records and consent violation.
Traps
- Releasing records to a family member without the patient's authorization.
- Charting "consent obtained" without any specifics.
- Retaining records for less than the required period.
- Treating a minor without guardian consent.
- Altering records after a bad outcome.