Clinical records, confidentiality, and billing practices
Records questions combine clinical documentation, privacy, and payment integrity. The exam tests whether the record tells the story and whether disclosure or billing matches authorization.
Core rules
- Create contemporaneous, legible records: identity, history, exam, diagnosis, treatment, response, consent, referrals, and instructions. Corrections should be dated and traceable, not obliterated.
- Retain records for the period required by Board rule, payor contracts, and statutes; minors and pending claims may require longer retention.
- Confidentiality: disclose protected health information only with valid authorization, for treatment, payment, or operations, or as law requires. Minimum necessary applies.
- Billing must reflect services actually provided and documented. Upcoding, unbundling, billing for unlicensed delegates, and routine waiver of copays can be fraud.
- Patients generally have access rights; know the state and federal exceptions.
Worked example
An insurer asks for the entire chart for a three-visit claim. The office sends all records, including unrelated psychotherapy notes, without review. The problem is over-disclosure: the response should be limited to the authorized, minimum-necessary scope unless a broader valid authorization exists.
Traps
- Backdating a late note.
- Destroying records during a complaint.
- Billing a consultation when only an adjustment occurred.
- Releasing records on a phone request without identity verification.