Recordkeeping, Documentation, and Patient Confidentiality
What a defensible record contains
Minnesota expects a contemporaneous, legible, authenticated record for each encounter: date and patient identity; chief complaint and history; examination findings, including the specific segmental levels and direction of any subluxation; x-ray findings and the clinical rationale for imaging; diagnosis or clinical impression; treatment actually rendered; the patient's response; and evidence of informed consent. Entries made later are addenda, dated, initialed, and explained, never silent alterations of the original.
Retention and release
Retain records for the period set in Minn. R. ch. 2500, and verify the current figure with the Board; as a practical floor, keep them at least seven years past the last service and longer for minors. Release is governed by the Minnesota Health Records Act, Minn. Stat. sections 144.291 to 144.298. A valid authorization is written, dated, signed, identifies the recipient and the information, states the purpose and an expiration date, and notes the patient's right to revoke. A subpoena is not self-executing: confirm a court order or valid authorization, and give the patient the notice the statute and rules require before producing anything. Reasonable copying fees may be charged.
Worked example
An attorney subpoenas a patient's chart in a personal injury suit. The correct sequence is to check for a signed authorization, notify the patient of the subpoena, and produce only what the order or authorization covers. Mailing the entire chart the same afternoon is a confidentiality violation, and the fact that the subpoena looked official is no defense.
Traps
Releasing records on a spouse's or employer's oral request; faxing to an unverified number; assuming HIPAA preempts stricter Minnesota consent rules, which it does not; failing to document a patient's refusal of care or a missed appointment together with the advice given.