Patient Records, Informed Consent, Confidentiality, and Patient Rights
Record content and retention
Records must be complete, legible, contemporaneous, and retrievable. Expect medical history, examination findings, diagnosis, treatment plan, anesthesia and medications, radiographs, consent documentation, referrals, and communications. Retention follows Board rule; keep records longer for minors and for any matter under complaint. Never alter an entry retroactively - add a dated addendum. The record is the best evidence in a complaint, and a thin record is itself a rule violation.
Patient access
Patients have a right to copies of their records under the Minnesota Health Records Act (Minn. Stat. ch. 144.291–.298) and HIPAA. Where the two differ, the more protective standard governs - a common trap is the belief that HIPAA always preempts state law. Fees are limited to the statutory allowance, and records cannot be withheld because a bill is unpaid.
Informed consent
Consent must be informed: diagnosis, nature of the procedure, material risks, benefits, alternatives (including no treatment), who will perform it, and cost implications. Document who consented, when, and what was discussed; a signature on a blank form is not informed consent. Minors require a parent or guardian. Photography, marketing use, and release of information to third parties require a valid authorization; mandated reporting of suspected maltreatment and court orders are exceptions.
Traps
Assuming records belong to the dentist so no copy is owed; treating a phone call as consent for surgery; disclosing to a spouse or employer without authorization; abandoning a patient without written notice and time to transfer.
Rule of thumb: if it is not in the record, it did not happen - and if it is in the record improperly, it happened and you own it.