Callie, an RN, knows that another nurse at her facility is treating a client with Guillain–Barré syndrome. Callie has never treated a client with Guillain–Barré syndrome before. She wants to know more about the client’s health care plan so she can increase her knowledge of the disease and be better prepared to provide care for future clients. Because she believes reading the chart has educational value, Callie accesses the client’s chart. Should Callie have done so?
You can only access a client’s health records in order to provide health care or to assist in providing health care to the client. No matter what your nursing role is, it is not appropriate to access a chart because you think it has educational value or you are curious about a particular clinical case. This is according to legislation, such as the Personal Health Information Protection Act, and College standards.
Protecting client information builds trust
Personal health information belongs to the client. You have a responsibility to maintain the confidentiality and privacy of a client’s personal health information. When caring for a client, you’re expected to obtain the client’s consent before collecting, using or disclosing their information outside the health team or circle of care. Find more information about this accountability in the Confidentiality and Privacy – Personal Health Information practice standard.
Respecting a client’s privacy and keeping their information secure and confidential is critical for establishing trust with them. Trust is essential when establishing and maintaining the nurse-client relationship because, as a client, they are in a vulnerable position. Confidentiality and privacy breaches may cause clients to mistrust the nurses caring for them and negatively affect the nurse-client relationship. To learn more about how trust impacts the nurse-client relationship, read the Therapeutic Nurse-Client Relationship, Revised 2006 practice standard.
As well, when a client trusts the nurses in their circle of care, it builds respect for the nursing profession. Conducting yourself in a manner that promotes respect for the profession is an accountability in the Professional Standards, Revised 2002 practice standard.
Often, the circle of care can include many health care providers. There are some specific nursing roles where it is inappropriate to access personal health information, even if you are in the circle of care. To learn more, read the Information and Privacy Commissioner of Ontario’s Circle of Care: Sharing Personal Health Information for Health-Care Purposes.
If you have questions about collecting, using or sharing client information, contact our Practice Support team.