Ob-Gyn Coding Alert

Answer: The legality in these cases will depend on individual state law. In some states, minors can consent to treatment, but other states require parental consent for specific types of services. As long as you are within the law, you can keep the records confidential.

Caution: If the child is endangering herself or others, document and report it to the necessary authorities as prescribed by your state laws or licensing regulations.

If the child is not a danger to herself or others and you are legally permitted to maintain confidentiality, you can document “DO NOT COPY OR RELEASE TO PARENTS” in the paper chart, EMR, and/or EHR. In addition, some physicians keep such documentation separate from the main chart in a confidential folder.

HIPAA: “The Privacy Rule generally allows a parent to have access to the medical records about his or her child, as his or her minor child’s personal representative when such access is not inconsistent with State or other law,” explains HHS Office for Civil Rights (OCR) guidance.

As mentioned above, state law is the top reason in determining a minor’s right to keep medical records confidential and from parents. OCR lists two other reasons why this might occur: First, a court order might decide a minor patient’s treatment or appoint another representative for the minor, and second, “the parent agrees that the minor and the healthcare provider may have a confidential relationship.”