Documentation, informed consent, patient rights, and confidentiality
What this domain tests
This domain tests whether your records tell the clinical story, whether consent is real and documented, and whether patient information is protected. Expect scenario questions about record release, corrections, and consent for treatment.
Core rules and concepts
- Documentation should be timely, accurate, dated, and authenticated. The record should include the initial examination, evaluation, diagnosis, plan of care, interventions, patient response, education, referrals, consent, and discharge summary.
- Correct errors without obliterating the original entry. Use a single line, date, initials, and a brief correction. Do not backdate or create late entries as if written earlier.
- Informed consent requires discussion of the nature of the proposed care, expected benefits, material risks, reasonable alternatives, and the right to refuse. Document the discussion and the patient's decision.
- Patient rights include respect, privacy, access to records, participation in care, and refusal of treatment. Confidentiality is protected by New Hampshire law and HIPAA. Release generally requires written authorization unless a legal exception applies.
- Retain records for the period required by Board rules and never destroy records during an open complaint or investigation.
Worked example
A patient asks for a copy of the therapy record. The clinic verifies the request and authorization, provides the permitted records, and documents the release. The PT does not alter the record to remove a disagreement about the plan. If the patient believes an entry is wrong, the proper step is an addendum or correction process, not deletion.
Traps that cost marks
Do not document treatment before it occurs. Do not release records to a family member without authority. Do not assume HIPAA allows every internal disclosure. Do not ignore a patient's refusal or question about risk.
Exam focus
Connect each scenario to one of four duties: accurate record, valid consent, protected information, or patient right to choose.