Confidentiality and Medical Records
According to a landmark law review article in 1890 on the right of privacy, the individual has the right to determine ordinarily to what extent his thoughts, sentiments and emotions shall be communicated to others. Whatever else privacy includes, clearly it involves personal control over information about ourselves, and of course access to that information. Without such personal control, human relationships and trust would be diminished. We grant healthcare providers access to personal information about us for assessment and therapeutic benefit, but we retain control over access to that information and authorize its release only when we choose to do so. This is certainly true of the practice of information sharing and record keeping.
The RHPA reminds us:
"Client information; both verbal and written is confidential and will be safeguarded by the therapist" and "Written authorization is required and will be obtained prior to all communications concerning the client health records." The question is sometimes raised however, how far ought a practitioner to go in record keeping? What kind of information should not be recorded and what guidelines ought to direct us in this task? First of all, it is universally agreed that untrue information should not be recorded, and questionable information should clearly be documented as questionable. For example, third party information about the client’s horse would obviously be questionable especially if the third parties are equine Health care providers with di ssenting opinions about the client’s horse and its condition.
Secondly, true information which is not relevant should not be recorded.
Thirdly, information about a client and the client’s horse should not be communicated to anyone without the client’s express written consent. Clients need to be able to determine who will know what about their horses as well as being provided with every possible assurance that information obtained about their horses will be treated with respect, privacy and dignity. Fourth, information recorded in the medical record can be of great harm or help. For this reason, practitioners need to exercise caution, discretion and sound judgement in record keeping. Irrelevant and potentially damaging comments regarding the client’s and or the client’s horse’s physical appearance, demeanour or attitude should not be recorded and forwarded to other practitioners unless such information is relevant to the proposed treatment and is presented in clinical and value neutral language, and with the consent of the client.
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