Patient rights, informed consent, confidentiality, and recordkeeping
Domain 5 covers patient rights, consent, confidentiality, and records. The exam favors answers that preserve autonomy and document the process.
Core rules
- Informed consent requires the patient’s voluntary agreement after explanation of the proposed OT, its nature, risks, benefits, reasonable alternatives, and the consequences of refusal. Document who consented and how.
- Adults are presumed to have capacity. For a minor or a patient without capacity, follow guardianship/health care proxy law and the setting’s policy; do not assume a family member can consent.
- Confidentiality is governed by HIPAA and New Jersey law. Share only the minimum necessary for treatment, payment, or operations, or with a valid authorization or legal exception.
- Exceptions include suspected abuse/neglect, serious imminent danger, public health reporting, and valid court orders/subpoenas handled through legal counsel.
- Records must be timely, objective, legible, and retained per Board rules and facility policy. Do not release records without proper authorization unless law requires it.
Worked example
A parent asks to see the OT record of a 16-year-old patient. The parent is the legal guardian and consents to treatment. Reasoning: the parent generally may access the minor’s record as personal representative, but the OT should follow the facility’s release process and any adolescent-confidentiality rule; the OT does not informally hand over the chart.
Traps
Treating a signed form as consent without explanation; letting a friend take records; disclosing to an employer without authorization; and destroying records during a complaint or subpoena.