The Instagram Photo and the Records Request
A Missouri dental hygienist takes a photograph of a patient's severe gingival enlargement during a periodontal maintenance visit. The patient's face is not visible, but a distinctive tattoo on the neck and a scar are visible. The hygienist posts the photo on her personal Instagram account with the caption 'Look at this crazy case from today! #dentalhygiene #perio.' A coworker comments with the patient's first name. Two weeks later, the patient's attorney sends a request for a complete copy of the patient's dental record, including radiographs. The office manager says the office will provide a summary but not copies because the patient has an unpaid balance of $240. The patient also asks for the original radiographs to be sent to a new dentist. The hygienist is asked to prepare the records.
1. Evaluate the Instagram post under Missouri ethics and confidentiality requirements.
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The post is a confidentiality violation. Even without the patient's face, the neck tattoo, scar, and clinical description make the patient identifiable to people who know her. A dental hygienist may not disclose identifiable patient information without authorization, and 'personal account' does not change that. The coworker's comment adding the first name makes the identification worse. This can be charged as unprofessional conduct and violates HIPAA privacy standards. The hygienist should remove the post immediately, preserve a copy for the investigation, report it to the dentist or privacy officer, and not argue that the photo was 'de-identified.' Discipline could include a reprimand, ethics CE, or probation.
2. Must the office release copies of the record and radiographs? Can it condition release on payment of the $240 balance?
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The patient is entitled to a copy of her dental record, including radiographs, and to have them sent to a new dentist with a valid authorization. The office may charge a reasonable, cost-based copying fee, but it cannot withhold the record because of an unpaid balance. A summary is not a substitute for the record the patient requests. The original radiographs belong to the practice, but the patient gets copies. The office should respond in writing, provide the copies promptly, and document the release. If the request is from an attorney rather than the patient, the office needs a valid authorization or legal process.
3. What should the hygienist do if the attorney sends a subpoena with no patient authorization?
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She should not release records on her own. She should give the subpoena to the dentist or office counsel immediately. A subpoena is not automatically a HIPAA authorization; the office must determine whether there is a court order, a satisfactory assurance that notice was given, or a valid authorization. If the demand is defective, counsel should object or seek clarification. The hygienist should document the date received, preserve the records, and not alter them. She should also keep the Instagram issue separate and not discuss the patient with the attorney outside the proper channel.