Confidentiality and Record Keeping in Clinical Practice

These flashcards summarize key concepts related to confidentiality, privacy, legal duties, and record-keeping as discussed in the lecture notes.

Confidentiality

A general standard of professional conduct that obliges a professional not to discuss information about a client with anyone.

Privacy

The basic entitlement of people to decide how much of their property, thoughts, feelings, or personal data to share with others.

Privilege

A legal protection from disclosure in legal proceedings.

HIPAA

The Health Insurance Portability and Accountability Act regulations that require privacy and security measures for health information.

Duty to Warn

A legal obligation to protect third parties against dangers posed by a client.

Records

Documents created and maintained by a clinician that include treatment, assessment, and other relevant information.

Electronic Medical Records (EMRs)

Digital versions of patients' paper charts that contain the medical and treatment history of patients.

Retention Period

The minimum timeframe that treatment records must be maintained, which is seven years in Massachusetts, with some rules applying to minors.

Subpoena vs. Court Order

A subpoena requires a response but not necessarily production of records; a court order requires compliance and exact records.

Informed Consent

The process of providing sufficient information to a client so that they can make a knowledgeable decision about their treatment.