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Accessing client’s health records

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.  

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. 

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. As well, when a client trusts the nurses in their circle of care, it builds respect for the nursing profession. Confidentiality and privacy breaches may cause clients to mistrust the nurses caring for them and negatively affect the nurse-client relationship.  

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 Ontario Privacy Commissioner’s Circle of Care: Sharing Personal Health Information for Health-Care Purposes.

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Page last reviewed November 19, 2018