Recordkeeping, Privacy, and Informed Consent
Record content and retention
A dental record must be contemporaneous, legible, complete, and authenticated. Know the required elements: patient identification, medical and dental history, clinical findings, diagnosis, treatment plan, informed consent documentation, progress notes, radiographs, medications prescribed, and referrals. Retention periods are set by statute or rule and often run from the later of last treatment or the patient's majority for minors. Traps: assuming records belong to the patient (the practice owns them; the patient has a right of access); assuming a brief note suffices for a significant event; and backdating or altering records, which is itself unprofessional conduct and destroys credibility.
Privacy
Privacy obligations arise from professional ethics, the act, and health information statutes. The core rule: disclose only the minimum necessary, only with valid authorization or a legal exception (treatment, payment, operations, required reporting, court order, or serious threat). Know that a subpoena may require a patient authorization or a court order depending on the jurisdiction, and that a question offering "release everything requested" is usually wrong.
Informed consent
the elements: diagnosis and nature of the condition, nature and purpose of the proposed treatment, material risks and benefits, alternatives including no treatment, and the consequences of declining. Consent must be voluntary and obtained from a competent patient; for minors, a parent or guardian, subject to statutory exceptions (emancipated minors, emergency). Traps: assuming a signed form alone is consent (the discussion is the consent; the form is evidence); assuming consent to one procedure covers extensions; and assuming consent is unnecessary because a procedure is routine.
Worked example
A patient requests copies of records and the practice demands payment of an outstanding balance first. Rule of thumb: access generally cannot be conditioned on payment of the balance; a reasonable copying fee may be charged where authorized.