Patient Records, Confidentiality, Informed Consent, and Release of Information
The record
The patient record is the contemporaneous account of examination, diagnosis, treatment, and advice-including the informed-consent discussion. Board rules require retention for a defined period after the last professional service; records for minors are kept longer, typically until the age of majority plus the retention period. Store records securely and back them up.
Confidentiality and release
Patient information is confidential. Release requires a written authorization that identifies the information, the recipient, the purpose, and an expiration, unless a legal exception applies-emergency treatment, court order or subpoena, public health reporting, or the board's investigation. HIPAA sets a federal floor; Missouri law and board rules may add requirements.
Access and informed consent
Patients have a right to inspect and obtain copies of their records, with limited exceptions. Consent to treatment must be informed: diagnosis, nature of the proposed treatment, risks, benefits, alternatives, and the consequences of declining. Document the conversation and the patient's questions.
Worked example. A former patient requests copies of her record. The office asks why she wants them and delays. That is improper: a patient need not justify a request for her own record. The office should verify identity, provide copies in the required format and time, and charge only permitted fees.
Traps. Releasing records on a phone request without identity verification; withholding records because of an unpaid bill, which is generally not permitted; discussing a patient in a public area; assuming HIPAA preempts all state law.