When Clients Ask for Their Records – Release of Information Tips

I recently had the pleasure of being a guest on Kayla Das’ The Designer Practice Podcast, where we talked about an important topic for therapists and coaches: managing the release of information when it comes to record disclosure requests.

During the podcast, we covered a range of topics that are essential for therapists and coaches to understand. Here is a summary.

Listen to the full podcast “Episode 5: When Your Client Asks for a Copy of Their Therapy Record with Jean Eaton” for more insights and details.

Client’s Rights and Therapist’s Obligation

Individuals have the right to privacy and can choose what information they share and with whom they share it. As a therapist or business owner, it is your obligation to keep the information that patients or clients share with you confidential and secure.

Case Note Retention Practices

Therapists have an obligation to keep patient information confidential and secure, and to maintain records for the required retention period. The retention period varies depending on the province and discipline, but it is generally 10 years (plus the age of majority. It’s important to ensure that you keep control of the patient information for the entire retention period whether it’s on paper, electronic, or in the cloud.

Reasons Why a Client Might Request a Copy of Their Therapy Record

It is important to inform clients about the purpose of collecting their identifying information, as well as encouraging them to regularly review their records for accuracy.  The client has the right to access a copy of their own information. Trust is a key factor in building a positive therapist-patient relationship, and open communication about record-keeping practices can help establish that trust.

Conversation with Client About Release of Information

At the time that you collect information from the client is the ideal time to discuss with the individual about what information is being collected and how it will be used. This is also an opportunity to discuss how the information may be shared in the future.

Best Practices for Third-Party Disclosure Requests with Client’s Expressed Consent

To ensure patients’ information is not disclosed without their consent, it’s important to have a conversation with them about what information is being collected and how it will be used. If a patient expressly states how they want their information shared (or not shared), you must record their wishes in their file and follow those instructions.

Privacy Legislation

All businesses must comply with privacy legislation. Therapists and life coaches in Canada will likely follow PIPA or PIPEDA legislation. Regulated health professionals (like registered nurses, physicians, pharmacists, chiropractors, and other custodians) working in private practice in Alberta are guided by the Health Information Act.

Best Practices for Third-Party Disclosure Requests Without Client’s Expressed Consent

Before disclosing any information without a client’s expressed consent, one should first determine if there is an immediate safety concern. If there is no immediate danger, it is essential to have the right paperwork in place, and appropriate legal authorization should be obtained before releasing any information without the client’s consent.

How to Manage a Conversation with a Third-Party Before Client Consent is Obtained

When managing a conversation with a third party before obtaining client consent, it is important to have a prepared script to respond to the request. The person making the request should know their legal authority and provide the request accordingly.

Considerations When Using Online Communication to Connect with Client

The use of technology in healthcare requires a proper risk assessment and due diligence to ensure that patient information is secure. Healthcare providers cannot transfer all the risks to the patient and need to take responsibility for the technology they use.

See the Practice Management Success Tip, “Can You Use Text Messaging With Patients?” for more help.