Patient Records, Informed Consent, and Confidentiality
What the exam tests
Questions test documentation standards, the elements of valid consent, minors and substitute decision-makers, and the permitted exceptions to confidentiality.
Core rules
- Records must be accurate, legible, contemporaneous, and complete: history, findings, diagnosis, treatment, anesthesia, and instructions. Corrections should be dated and identified, not erased.
- Informed consent requires disclosure of the nature of the procedure, material risks, benefits, alternatives, and the consequences of declining, followed by voluntary authorization.
- Minors generally require a parent or legal guardian’s consent, subject to specific statutory exceptions.
- Confidentiality protects patient information; disclosures may be permitted or required for treatment, payment, operations, abuse reporting, court orders, and public-health requirements.
- Patients have rights to access and authorize release of their records under applicable Illinois and federal law.
Worked example
A patient requests a copy of her records. The office refuses because the dentist has not “released” them. That is wrong: the patient is entitled to access and authorization controls release to third parties. The office should follow its verification and copying procedures, document the request, and avoid altering the record after the request.
Traps
- Backdating or editing a record after a complaint or records request.
- Accepting a consent signed by a minor without checking the exception or guardian status.
- Discussing a patient in a hallway, elevator, or on social media.
- Treating confidentiality as absolute; know the mandated exceptions.