Patient Records, Ethics, and Administrative Duties
The Record as a Legal Document
The chart is a legal document and can be subpoenaed. Entries are made in ink, contemporaneously, and are dated and signed or initialed. Never erase, use correction fluid, or backdate. Correct an error with a single line through the entry so the original stays legible, then initial, date, and note the reason. Never alter a record after a patient requests copies or after an adverse event.
Confidentiality and Consent
HIPAA permits disclosure for treatment, payment, and operations; anything else requires a signed authorization. Release only the minimum necessary information. Records of minors are handled with the parent or legal guardian. Informed consent requires capacity, disclosure of risks, benefits, and alternatives, and voluntariness - a signed form is evidence of the conversation, not a substitute for it.
Ethics and Scope of Practice
Core principles are autonomy, beneficence, nonmaleficence, justice, veracity, confidentiality, and fidelity. The state dental practice act defines which RDA duties require direct, indirect, general, or personal supervision. Performing an expanded function outside your scope is a licensing violation even when the dentist requests it. Report suspected child, elder, or dependent-adult abuse as state law requires.
Traps
Distractors include documenting a missed appointment as completed treatment, billing for a service never rendered (fraud), and discussing a patient’s care in a hallway or elevator.
Worked Example
A dentist asks you to change a chart note from “crown seat” to “crown seat and endo” although no such procedure occurred. You decline and instead offer a properly dated, initialed addendum. Rule of thumb: amend, never alter.