Recordkeeping, Documentation, Informed Consent, and Patient Confidentiality
Recordkeeping, Documentation, Informed Consent, and Patient Confidentiality
The record
Every encounter should generate a contemporaneous entry containing identifying data, history and presenting complaint, examination findings, diagnosis, imaging ordered or performed with interpretation, treatment plan with goals, the specific treatment delivered and the response, informed consent, referrals, and discharge notes. Records must be legible, dated, and authenticated, and retained for the period Board rules set - at minimum the adult retention period, and for minors until majority plus that period. Never destroy records under subpoena or tied to a complaint.
Access and confidentiality
Disclose patient information with a valid authorization, for treatment/payment/operations, or as the law requires (subpoena, Board investigation, mandatory report, public health). Louisiana's health-records access statute lets patients obtain copies and caps copying charges; requests should be answered within the statutory time.
Informed consent
Consent is a process, not a signature. Discuss diagnosis, proposed technique, material risks (including the rare but serious vascular events associated with cervical manipulation), expected benefits, alternatives including no treatment, and invite questions. Document who consented and when; minors require a parent or guardian.
Worked example
Three months after care ends, a patient's attorney requests the file. The office adds a "clarifying" addendum to the initial exam to strengthen the record. Reasoning: supplementing the chart after a records request is alteration of the record - a separate, career-threatening violation. A late entry must be clearly labeled as added later, dated, and signed.
Traps that cost marks
- Undocumented consent and undocumented informed refusal.
- Withholding records over an unpaid balance where the access statute requires release.
- Assuming HIPAA preempts stricter Louisiana confidentiality rules; it sets a floor, not a ceiling.