Documentation, informed consent, and patient-record retention requirements
This domain tests the licensee’s documentation duties and the legal requirements for informed consent and record retention. Exam questions often ask what must be documented, how long records must be kept, and when records must be released.
Documentation and informed consent
Ohio rules require legible, accurate, and complete patient records. Documentation should include history, examination findings, diagnosis, treatment plan, informed consent, progress notes, referrals, and communications. Informed consent must cover the nature of the proposed care, material risks, benefits, alternatives, and the consequences of declining care. Consent may be oral or written, but written consent is easier to prove; the discussion should be documented in the record.
Record retention and release
Records must be retained for at least seven years after the last treatment. For minor patients, retention extends as specified by rule, generally until the patient reaches majority plus the retention period. Records must be released to the patient or an authorized representative upon proper request, subject to allowable copying fees and applicable privacy laws.
Worked example
A patient requests a copy of her records. The chiropractor should verify identity or authorization, provide a complete copy within a reasonable time, and document the release. The chiropractor may charge a permitted copying fee but cannot withhold records to collect an unpaid bill.
Traps
Do not rely on memory for consent; document it. Do not alter records after a complaint; late entries should be clearly identified. Do not withhold records for unpaid fees. Do not retain records for less than seven years.