Patient Rights, Informed Consent, Confidentiality, and Documentation Requirements
Informed consent
Patients have the right to make informed decisions. Consent should cover the nature of the proposed PT, expected benefits, material risks, reasonable alternatives (including no treatment), and the right to withdraw. Consent may be oral or written depending on the situation, but high-risk or sensitive interventions need clear documentation. Minors and incapacitated adults raise additional consent rules.
Confidentiality
Protected health information is governed by HIPAA and Oregon law. Disclose only with valid authorization or a legal exception (treatment, payment, operations; required reporting; serious threat). Do not discuss patients in public areas or on social media. Release the minimum necessary information.
Documentation
The record must be accurate, legible, dated, and authenticated. It should show the initial examination, PT diagnosis, plan, progress, changes, education, and discharge. Late entries should be labeled as late, not backdated. Retain records per Board rule and organizational policy.
Worked example
A patient asks for a copy of her PT record. The clinic verifies identity, provides the requested records within the legal timeframe, and documents the request. If another provider needs records, the clinic uses a valid authorization unless an exception applies. The PT does not alter the record after the request.
Traps
Do not confuse consent to treat with informed consent for every intervention. Do not share patient details in a public social media post even without a name. Do not backdate a note. Do not release the entire chart when a limited summary would satisfy the request.