Patient Records, Confidentiality, and Informed Consent
Domain 6 - Patient records, confidentiality, and informed consent
This domain tests the legal life of the clinical record: what must be documented, who may see it, how long it is kept, and how consent is obtained. Questions often turn on requests from employers, attorneys, or family members.
Core rules
- Records must be legible, complete, timely, and sufficient to support the diagnosis and treatment. Informed consent discussions, referrals, and patient instructions should be documented.
- Retention periods are set by statute or Board rule; records for minors generally must be kept longer. When in doubt, retain rather than destroy during an open complaint or litigation.
- Confidentiality protects identifiable patient information. Release generally requires a valid written authorization, except for treatment, payment, emergencies, or reports required by law.
- Informed consent requires explaining the diagnosis, proposed care, material risks and benefits, alternatives, and the consequences of declining. Consent must be voluntary and documented.
- Patients generally have a right to access their records; a licensee cannot withhold records solely because a bill is unpaid.
Worked example
An employer asks for an employee’s complete eye record after a workplace injury. The optometrist should release only what is authorized or legally required. A general employer request is not automatically a valid patient authorization. If the patient signs a specific release, disclose only the requested information.
Traps
Do not alter a record after a complaint; make a late entry clearly. Do not discuss a patient in a public area. Do not treat HIPAA as the only rule; Nebraska law and Board rules also apply. Do not assume a family member has automatic access.