Patient records, confidentiality, and informed consent
What this domain tests
This domain tests documentation, privacy, and consent as legal duties. Montana Board rules require accurate records; HIPAA adds federal privacy and security duties. Informed consent is both an ethical and a documentation issue.
Core rules
- Keep a complete record: history, examination, diagnosis, treatment plan, progress notes, radiographs, medications, referrals, and informed consent. Entries should be timely, legible, signed, and corrections should be dated without obliterating the original.
- Retain records for the period required by Montana law and Board rule. A common compliance anchor is at least seven years from the last treatment, and for minors until the age of majority plus the retention period. Confirm the current ARM citation before destroying records.
- Protect confidentiality. Release records only with a valid signed authorization, for treatment, payment, or operations, or as required by law, subpoena, or mandatory reporting. Use minimum necessary and secure storage.
- Obtain informed consent: diagnosis, nature of procedure, risks, benefits, alternatives, and consequences of refusal. Document who consented and when. Minors generally require a parent or guardian, subject to limited legal exceptions.
Worked example
A patient’s employer calls asking whether the patient had a crown. Without authorization, the hygienist should not confirm even that the person is a patient. A subpoena is handled through the custodian of records and legal review, not by reading the chart over the phone.
Traps
“It’s in the chart” does not cure missing consent. Altering a record after a complaint is a serious credibility problem. Do not release the entire record when a limited authorization covers only part.