Legalities

Confidentiality, Informed Consent and Client Records

The following information is useful for all clients to understand

Confidentiality

Clients have a right to privacy.  Contents of therapy are not revealed without informed consent.  One of the main purposes for obtaining a client’s consent before speaking to a third party (such as another agency or a family member /carer) is to protect the confidentiality and privacy of the client.

Confidentiality will need to be broken however if there is disclosure or evidence, of physical, sexual or serious emotional abuse or neglect; if suicide is threatened or attempted;  or where there is disclosure or evidence of serious self-harm (including drug or alcohol misuse that may be life-threatening), or where there is a threat to harm another person.

Information about the client may also be revealed to a third party if there is a clear legal reason.  Following is a more detailed account of exceptions to confidentiality.

Limits of confidentiality

What is discussed during therapy is kept confidential.  No contents of the therapy sessions, whether verbal or written may be shared with another party without client consent, or the legal consent of the client’s legal guardian.  The following is a list of exceptions:

Duty to Warn and Protect
If the client discloses a plan to threat or harm him /herself, the therapist must attempt to notify the family (depending on client’s age) and legal authorities.  In addition, a disclosure to plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.

Abuse of Children and Vulnerable Adults
If it is disclosed, or suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled /incompetent), the therapist must report this information to the appropriate state agency and /or legal authorities.

Prenatal Exposure to Controlled Substances
Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.

Minors /Guardianship
Parents or legal guardians of minor clients have the right to access the client’s records.

Insurance Providers
Insurance companies and other third-party payers are given information that they request regarding services to the clients.  The type of information that may be requested includes; types of service, dates /times of service(s), assessment, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc.

Informed consent

Informed consent is a legal procedure used to gain permission and ensure the client is aware of all potential risks and costs involved in a treatment procedure.  Each client, before commencing any form of psychotherapy will be required to sign consent in their client intake form.

Client records

Client records are kept for the purpose of document and review, and to protect from public liability in the case of legal or ethical proceedings.

Client records contain information (including information stored electronically) used to document the nature, delivery, progress, or results of therapy.

Records include: identification data, referral information, dates, types of services, fees, and anything else documented e.g., treatment plans and consultation notes.

Records may be created and maintained in a variety of media, including electronic systems, so long as their utility, confidentiality and durability are assured.  All records are kept safe and secure, with properly limited access, and where timely retrieval is possible.  With electronic and web-based systems, there are appropriate encryption and security systems in place.