Patient Records, Confidentiality, and Informed Consent
Records
Patient records must be legible, accurate, timely, and sufficient to support the diagnosis and treatment. They include history, examination findings, test results, diagnoses, prescriptions, consent, and communications. The Board expects retention consistent with its rules and with malpractice and statutory limits; when in doubt, retain longer for adults and minors. Records are the property of the practice, but patients have rights of access.
Confidentiality and consent
- Release protected health information only with valid authorization or a legal exception, such as required reporting, court order, public health, or treatment coordination.
- HIPAA and NC law both matter. A state rule can be stricter; follow the stricter requirement.
- Informed consent requires discussion of diagnosis, proposed treatment, material risks, benefits, alternatives, and consequences of refusal. Document the discussion, not just a signature.
- Minors and incapacitated adults raise special consent issues; identify the authorized decision-maker.
Worked example
A patient asks for a copy of her record to take to a new optometrist. The practice should provide it promptly under its access policy and may charge only an allowed fee. It should not refuse because the patient has an unpaid balance or because the OD wants to keep the patient. Refusing access can trigger both HIPAA and Board complaints.
Traps that cost marks
- Charting “consent obtained” with no substance.
- Releasing records to an employer or school without authorization.
- Assuming a signature is always required for every disclosure; some exceptions apply.
- Altering a record after a complaint; late entries must be clearly identified.