Recordkeeping, Informed Consent, Patient Confidentiality, and Documentation
Domain 5: Recordkeeping, Informed Consent, Patient Confidentiality, and Documentation
This domain tests the clinical and legal record. The exam focuses on what must be documented, when consent must be obtained, and when patient information may be released. Mississippi Board rules operate alongside federal and state confidentiality law.
Core rules
- The record should identify the patient, history, examination findings, diagnosis, treatment plan, informed consent, services rendered, response to care, and referrals.
- Informed consent must be obtained before treatment and documented. It requires explanation of the proposed care, material risks, alternatives, and the opportunity to ask questions.
- Patient information is confidential. Release generally requires patient authorization or a legal exception such as subpoena, public health reporting, or abuse reporting.
- Board rules set retention periods; a common compliance practice is at least seven years after the last service for adults, and for minors until majority plus the retention period. The current Board rule controls.
- Records must be legible, timely, authenticated, and not altered improperly after the fact.
Worked example
A 16-year-old presents with a parent. The chiropractor explains the adjustment and risks to both. The parent signs consent, and the note records who consented, what was explained, and the minor's assent. If the parent later requests records, the practice follows authorization and retention rules rather than releasing them informally.
Traps
Do not rely on a generic signed form without documenting the discussion. Do not release records to an attorney without proper authorization or legal process. Do not alter a record after a complaint; late entries must be clearly identified.