Standards of Professional Conduct, Ethics, and Patient Recordkeeping
What this domain tests
This domain tests fiduciary conduct and records: informed consent, confidentiality, accurate documentation, release of records, retention, and relationships with patients and staff.
Core rules and concepts
- Obtain informed consent for treatment, especially when discussing risks, alternatives, and off-label use. Consent must be documented when significant.
- Patient information is confidential. Release requires patient authorization or a legal exception such as a subpoena, court order, or required public-health report.
- Records must be legible, dated, authenticated, and sufficient to support the diagnosis and treatment. Include chief complaint, findings, assessment, plan, medications, and instructions.
- The Board expects records to be retained for at least the period set by its rules; five years from the last professional service is a common benchmark, and minors or special circumstances may require longer retention.
- Patients are entitled to copies of their records and prescriptions under applicable law; do not condition spectacle or contact lens prescription release on purchase.
Worked example
A patient requests a copy of her record and spectacle prescription to use at another optical. The practice may charge a permitted copying fee but cannot refuse release because the patient is not buying glasses there. The record should be released promptly and the disclosure documented. Reasoning: patient access and prescription portability outweigh the practice's commercial interest.
Traps that cost marks
Altering a record after a complaint; releasing records to a spouse without authorization; and writing vague notes such as 'exam normal' without findings.