Patient Records, Informed Consent, Confidentiality, and Reporting Obligations
Records and consent
This domain tests documentation, informed consent, confidentiality, and statutory reporting. Nevada law and Board rules require records that justify care and protect patients.
- Keep contemporaneous, legible records: history, examination, diagnosis, treatment plan, informed consent, progress notes, and referrals. Nevada retention rules generally require retention for at least five years, with special handling for minors and disputes; do not destroy records under investigation.
- Informed consent must cover the diagnosis, proposed care, material risks and benefits, alternatives, and likely consequences. Document the discussion; a signed form alone is not a substitute for an actual explanation.
- Confidentiality: release records only with a valid authorization, a court order, or a legal mandate. Use minimum necessary disclosure.
- Reporting duties include child abuse or neglect, elder or vulnerable-adult abuse, and communicable diseases as required by Nevada law.
Worked example
An attorney requests records without the patient’s signature. The correct response is to decline until a valid HIPAA-compliant authorization or subpoena with proper notice is received. The reasoning: patient authorization is the default gateway; a subpoena may compel production but must be validated under the applicable procedure.
Traps
Releasing records to a spouse or employer without authorization; altering records after a request; withholding records solely because of an unpaid bill where law requires production; documenting consent only as “consent obtained.” Those are common record and confidentiality failures.