Patient Records, Informed Consent, and Confidentiality
Records and retention
Michigan requires dental practices to keep patient records that are accurate, complete, and legible. A record should include the health history, examination findings, diagnosis, treatment plan, informed consent, radiographs, medications, progress notes, and referral information. Board rules generally require retention for at least seven years after the last treatment; for minors, keep records until the patient reaches majority plus the retention period. Never alter a record after a complaint or lawsuit; add a dated addendum instead.
Informed consent
Informed consent is a process, not just a signature. The patient must understand the diagnosis, proposed treatment, material risks and benefits, alternatives, and the consequences of no treatment. For minors, obtain consent from a parent or legal guardian. Document who consented, what was discussed, and the patient's questions.
Confidentiality
Patient information is confidential under HIPAA and Michigan law, including the Medical Records Access Act. Release records only with a valid written authorization or as required by law, such as a court order, abuse reporting, or public health requirement. Patients have a right to inspect and copy their records; the practice may charge a permitted fee.
Worked example
A patient requests a copy of her records. The practice should verify identity, provide a copy in the requested format within the statutory time frame, and charge only the permitted fee. It should not refuse because the patient has an unpaid balance.
Traps
Do not discuss patients in public areas or on social media. Do not treat a minor without guardian consent except in an emergency. Do not destroy records while a complaint or litigation is pending.