Patient Records, Informed Consent, and Confidentiality
What the exam tests
This domain tests record content and retention, the informed-consent process, and permitted disclosures of patient information under New Hampshire law and HIPAA.
Core rules
- Records must be legible, dated, authenticated, and complete enough to justify the care. Document findings, treatment, anesthesia, radiographs, referrals, and patient instructions.
- Retain records for the period required by Board rule and HIPAA. For minors, retention generally runs until the patient reaches majority plus the required period.
- Informed consent is a process, not just a signature: diagnosis, nature and purpose of treatment, risks, benefits, alternatives, and consequences of refusal. Document informed refusal.
- Confidentiality exceptions include mandatory abuse reporting, court orders, public health requirements, and payment or treatment disclosures authorized by the patient.
Worked example
A patient refuses bitewing radiographs after the dentist explains the findings and risks. Reasoning: document the discussion, the patient's reason, and the refusal in the record; continue appropriate care within the patient's decision. Do not alter the record later to suggest consent was given.
Traps that cost marks
Assuming a signed form proves informed consent; discussing a patient on social media; releasing records to a family member without authority; and forgetting that mandatory reporting overrides ordinary confidentiality.