Patient Records, Informed Consent, Confidentiality, and HIPAA
What this domain tests
This domain covers record content and retention, patient access, informed consent, and privacy. Exam items test what must be documented, who may see records, and when a signed form is not enough.
Core rules
- The dental record must be accurate, timely, and sufficient to support the care provided. It includes history, findings, diagnosis, treatment plan, progress notes, radiographs, medications, and communications.
- Oregon rules set a minimum retention period; for minors, retention extends past the age of majority as specified in rule. Records should be retained for the required period even after a practice closes.
- Patients have a right to access and copy their records. A reasonable cost-based fee may be charged, but records cannot be withheld solely because a bill is unpaid.
- Informed consent is a process of discussing diagnosis, proposed treatment, risks, benefits, alternatives, and consequences of refusal. A signature is evidence of consent, not a substitute for the discussion.
- HIPAA requires minimum necessary use and disclosure, safeguards, and breach notification within 60 days of discovery.
Worked example
A former patient requests a copy of her radiographs and chart notes and owes a balance. The front desk may charge the allowed copy fee but may not refuse the request because of the debt. The hygienist should verify identity and authorization, release only the requested records, and document the disclosure.
Traps that cost marks
Treating a signed consent form as complete consent. Releasing records to a family member without authorization. Withholding records for unpaid fees. Ignoring the minor's guardian consent rules. Failing to document a refused treatment or referral.