Patient Records, Documentation, and Confidentiality
What the exam tests
Patient Records, Documentation, and Confidentiality tests record content, retention, access, correction, and permitted disclosure. Expect scenarios involving third-party requests, minors, legal demands, and privacy breaches.
Core rules
- Each record should be contemporaneous, legible, dated, and authenticated. It should show history, examination, diagnosis, treatment, advice, informed consent, referrals, and response to care.
- Records belong to the practice or practitioner, but patients have rights of access and correction under privacy law.
- Retention periods are set by regulation or law and run from the last date of care; do not destroy records early or after a complaint is filed.
- Disclosure requires valid consent, except where law compels it, such as a court order or public-health reporting, or where there is a serious risk of harm.
- Release only the minimum necessary information to the authorized recipient, verify identity, and log the disclosure.
Worked example
A lawyer sends a signed authorization for 'all records' for a patient involved in a motor-vehicle claim. The chiropractor verifies the signature against the file, notes that the authorization is limited to the accident-related treatment, and releases only those notes-not unrelated marital counselling notes kept in the same file. The reasoning is that consent defines scope; a broad phrase does not override privacy law or the duty to minimize disclosure. A disclosure log is completed.
Marks-losing traps
Altering records after a request or complaint; releasing records to a spouse or employer without patient consent; using a retention period that is too short; omitting consent discussions; and assuming that 'the patient's lawyer asked' is itself authority.