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Ensuring Confidentiality and Access to Medical Records: A Professional Perspective

In the realm of healthcare, maintaining the confidentiality and privacy of clients' health information is a paramount concern. It is crucial for healthcare professionals to adhere to strict guidelines and regulations to protect the sensitive data stored in medical records.



Confidential

The Significance of Privacy and Confidentiality

The right to privacy and confidentiality of clients' health information is not only a fundamental right but also a legal obligation governed by numerous laws. Clients can be assured that both handwritten and electronic medical records are treated with the utmost confidentiality. The laws ensure that healthcare providers handle this information responsibly, protecting it from unauthorized access or disclosure.

Nurses' Responsibility in Maintaining Confidentiality

Nurses, as integral members of the healthcare team, have a crucial role in upholding confidentiality. They are bound by the rules outlined in section 60.4 of the Professional Code (CQLR, chapter C-26) and must adhere to the provisions set forth in section 31 of the Code of Ethics of Nurses. These regulations emphasize the importance of preserving the secrecy of confidential information obtained during the course of their professional duties.


Section 60.4 of the Professional Code (CQLR, chapter C-26)


Every professional must preserve the secrecy of all confidential information that becomes known to him in the practice of his profession.


He may be released from his obligation of professional secrecy only with the authorization of his client or where so ordered or expressly authorized by law.


The professional may, in addition, communicate information that is protected by professional secrecy, in order to prevent an act of violence, including a suicide, where he has reasonable cause to believe that there is a serious risk of death or serious bodily injury threatening a person or an identifiable group of persons and where the nature of the threat generates a sense of urgency. However, the professional may only communicate the information to a person exposed to the danger or that person’s representative, and to the persons who can come to that person’s aid. The professional may only communicate such information as is necessary to achieve the purposes for which the information is communicated.


For the purposes of the third paragraph, “serious bodily injury” means any physical or psychological injury that is significantly detrimental to the physical integrity or the health or well-being of a person or an identifiable group of persons.

Accessing Medical Records: Addressing Common Queries

Given the nature of their work, nurses often receive inquiries about accessing medical records. Let's address a few common scenarios and shed light on the rules that govern such situations:

  1. Verbal Authorization from a Nurse's Mother: Can a nurse consult their mother's medical file based on verbal authorization? The answer depends on the specific guidelines of the healthcare institution. However, it is essential to note that proper authorization, preferably in writing, is typically required to ensure compliance with confidentiality rules.

  2. Reviewing the File of a New Lover: Can a nurse access the medical record of a new partner to confirm the completion of STI testing? Again, this situation calls for adherence to confidentiality regulations. Unless the nurse is directly involved in the care of the individual or has a valid professional reason, accessing the medical record would be deemed inappropriate.

  3. Hospitalization of a Work Colleague: If a nurse's colleague is hospitalized, can they obtain information about their health status from their medical record? Privacy laws dictate that access to medical records should be limited to those with a legitimate professional need. Therefore, unless the nurse is directly involved in the colleague's care, accessing their medical record without proper authorization would be a breach of confidentiality.

Nurses DO NOT provide the medical records to the patient. The request for access must be sent to the person in charge of protection of personal information at the institution

"Archive department or medical record department".


Balancing Accessibility and Confidentiality

While advancements in technology have made accessing medical records more convenient, it is crucial to strike a balance between accessibility and maintaining confidentiality. Recent disciplinary council decisions have raised concerns about privacy breaches resulting from the misuse of technological tools.

In one case, a respiratory therapist was found guilty by her Disciplinary Council for inappropriately accessing clients' medical records without a valid professional reason. Similarly, a doctor faced consequences for consulting the medical records of a person with whom she had a non-therapeutic friendship. Such incidents erode public trust and highlight the need for healthcare professionals to preserve confidentiality diligently.

Professional Use and General Inspection

To reiterate, access to medical records, whether in handwritten or computerized form, should be limited to fulfilling professional requirements. It is important to note that in the event of a general inspection by the Direction, Supervision, and Professional Inspection of the Order of Nurses of Quebec (OIIQ), the consultation of previous client files is considered a professional use.

Confidentiality and access to medical records are critical considerations in the healthcare industry. Adhering to legal obligations and professional guidelines ensures the privacy and security of clients' health information. Nurses and other healthcare professionals play a pivotal role in upholding confidentiality, safeguarding sensitive data, and maintaining public trust.


NCLEX: National Council Licensure Examination, OIIQ: Ordre des infirmières et infirmiers du Québec, OIIAQ: Ordre des infirmières et infirmiers auxiliaires du Québec

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