Note Taking in Four Parts

Part 1: The essentials

Part 2: Special cases 

Part 3: Questions about the CRPO Standards of Practice

Part 4: PHIPA and Confidentiality

 

DISCLAIMER: Please do your own due diligence when you have questions or issues that could put you or your clients at risk. This blog series is the intellectual property of the OSRP and should not be copied or disseminated without the express permission from the OSRP. For more information, contact membership@psychotherapyontario.org.

Important Overarching Tip from the CRPO: seek legal advice when you’re unsure about anything that relates to confidentiality and disclosure. 

 

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As sole-practitioner therapists, we are considered the Personal Health Information Custodians under PHIPA (Personal Health Information Act). In an organization of multiple therapists, someone is assigned that role. 

Here’s what you need to know about your notes in relation to being the Personal Health Information Custodian:

    • The client owns their information and we take care of it as the custodian 
      • That means clients can request access to their information when they want 
      • If access would have an adverse impact on treatment or well being of the client, then we don’t necessarily have to release our clinical notes
        • When that happens, document the situation carefully
        • Consult a lawyer

     

    Question How do we best handle requests for notes?

    CRPO response

    The Health Information Custodian only needs to disclose as much as necessary 

    • Ask the person requesting the notes why the request is happening 
    • Explore the purposes of the notes with the person requesting them
    • Obtain the client’s consent if it’s not the client making the request
    • It may not be appropriate to turn over the whole record -- disclosing notes can be about cooperating, but it's also about maintaining obligations under PHIPA 
    • We have a duty to maintain privacy, confidentiality, disclosure 
    • We have a duty to obtain consent for the collection, use, and disclosure of Personal Health Information 
      • Be sure you have this conversation with the client about what we put into the clinical record and when there are limits to confidentiality 
      • Some therapists take very detailed clinical notes, some high-level; there are pros and cons for each. As custodian, keep in mind your client's context and any potential future requests for notes and how they may be interpreted

      Important to know: there are laws around gate keeping, consent, gathering information, how to handle breaches, such as filing a report with the courts if your notes are subpoenaed (it’s still considered a breach of confidentiality if a court orders your clinical records, but when it’s required it’s considered an acceptable breech). Reach these laws on the PHIPA website.

       

      Question: What happens when there is an accidental breach of confidentiality?

      CRPO answer:

      There are breaches and there are breaches. If you accidentally sent a cc to all your clients revealing all their emails to each other, this situation is not ideal, but it’s easily remedied. Do not fear CRPO reprisals in cases like these. The CRPO will not revoke a license if the therapist takes measures to rectify the mistake:

      • The College will follow up with the therapist because they have to, but if the therapist tries to rectify what they’ve done and have no history of breaches, then it’s just about more education on the protocols (e.g. the therapist may have to take a remedial course) 
      • The CRPO does not worry about one-off situations if the therapist has shown accountability; it’s then considered a learning opportunity for the therapist 

      If you have a breach of confidentiality, consult a lawyer. As part of your liability insurance through your association, you should have pro-bono access to lawyer.

      Tip: The Office of the Information and Privacy Commissioner of Ontario has a lot of great resources to help people understand the PHIPA.

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      This concludes our blog posts on note taking. We will continue to update this information as we learn more, or as folks ask more questions that we take to the CRPO. We encourage you to respond to these posts in the comments boxes below. We look at all the comments and do our best to get answers to your questions.

       


      2 Comments

      Pat · December 16, 2019 at 11:16 pm

      This 4 part series represents an astonishing amount of work; it’s also uncommonly “user friendly” in terms of the way you chose to organize the material and make accessible the key points, without losing context. Many thanks!

      Anne · January 6, 2020 at 2:18 am

      Thank you Liz for the clarity of presentation in these guidelines. The 4 posts are very helpful! I so appreciate your work on this.

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