Patient Records, Informed Consent, and Confidentiality
Records and consent
Indiana dentists must maintain patient records that accurately reflect history, examination, diagnosis, treatment, and communications. Records must be legible, timely, and retained for the period required by board rule; do not destroy records while a complaint, claim, or investigation is pending. Informed consent must be obtained before treatment and documented. The discussion should cover the nature of the procedure, material risks, alternatives, and the consequences of declining. Consent for minors generally requires a parent or authorized guardian.
Confidentiality and release
Patient information is confidential. Disclosure is permitted with authorization, for treatment coordination, or as required by law, such as public-health reporting or a valid subpoena. HIPAA sets a federal floor, but Indiana law and board rules may add requirements. Patients generally have a right to obtain copies of their records; a reasonable copying fee may be charged where permitted, but records cannot be withheld merely because a bill is unpaid.
Worked example
A patient requests a copy of her chart and the front desk refuses until an outstanding balance is paid. The refusal is improper. The patient's right to access her records is separate from the payment dispute. The practice should follow its authorization and fee policy, provide the copy, and pursue the balance through ordinary collection means. Retaliatory withholding can become a confidentiality and records violation.
Traps that cost marks
- Relying on verbal consent without documenting the discussion.
- Assuming HIPAA preempts all Indiana requirements.
- Altering a record after a complaint instead of adding a dated addendum.
- Releasing records without valid authorization or legal process.