Recordkeeping, Informed Consent, and Patient Confidentiality
Recordkeeping, Informed Consent, and Patient Confidentiality
This domain tests the documentary and consent duties that surround every patient encounter.
Core rules
- Records must be timely, legible, accurate, and sufficient to show the history, examination, diagnosis, treatment plan, informed consent, response to care, and any referrals.
- Retention must satisfy Board rules and any longer federal or payor requirement. Do not destroy records under investigation or subpoena.
- Informed consent requires explanation of the proposed care, material risks, benefits, alternatives, and the right to refuse. Document the discussion, not just a signature.
- Patient information is confidential. Disclosure requires patient authorization or a legal exception such as mandatory reporting, subpoena, public-health duty, or Board investigation.
- Patients generally have a right to access and obtain copies of their records under applicable law.
Worked example
A patient with neck pain asks about manipulation. The chiropractor explains the diagnosis, the proposed adjustment, risks such as soreness and rare vascular events, alternatives including conservative care and referral, and invites questions. The patient consents. The note records the discussion and the patient's choice. Later, an insurer requests records; the office sends only the authorized scope and keeps a disclosure log.
Traps
A signed form does not cure a missing consent discussion. Do not release records to a spouse or employer without valid authorization. Do not alter a record after a complaint; late entries must be clearly identified. Do not destroy records to avoid a Board request.