Requests for Client Information
As a general rule, personal health information (PHI) is private and cannot be disclosed without the express or implied consent of the client. For infants, this means any custodial parent can give consent for release of information. In cases of separated or divorced parents, the midwife should request a copy of the governing agreement to confirm custody rights for the child.
In most circumstances, client consent is provided implicitly (e.g., within the circle of care) or explicitly (e.g., a signed consent form). However, at times, maintaining the privacy of health information conflicts with effective law enforcement. The law provides exceptions where disclosure of PHI is either permissible or mandatory without client consent. For example, health-care providers have mandatory reporting requirements under the Child and Family Protection Act. In addition to the duty to report when child abuse or endangerment is suspected, midwives may receive requests for information about a client or infant where the law requires disclosure of PHI.
Before responding to requests for client information from someone acting in an official capacity (e.g., coroner, public health inspectors, the policy or Children’s Aid Societies - sometimes called CAS or Family and Child Services), consider the following:
- Be mindful of your legal obligations to protect PHI unless an exception applies.
- Verify that the request is authorized (see below for the powers of specific authorities). Keep copies of all written requests and document the disclosure of PHI in the client chart.
- If authorization cannot be confirmed, advise the requester of your privacy obligations and decline to share this information without authorization or consent.
- Some requests improperly include a warning not to seek to discuss the request with anyone else or to disclose it to an insurer. These bald warnings cannot prohibit a midwife from seeking advice from the AOM, HIROC or legal counsel. Midwives should always feel free to seek advice and guidance when responding to requests for PHI.
- Check what information must be disclosed. Do not provide more information than specifically requested.
- Respond as quickly as possible when there may be an immediate threat of harm, but where there is no immediate threat do not succumb to pressure to respond before you fully understand your legal responsibilities.
- Never allow documents to be taken from your possession without first making a copy. Officials have the authority to seize the original chart, but should allow a copy to be made and will often be satisfied with receiving a copy and leaving the original.
- Only disclose information for the person(s) identified in the warrant or request (i.e., either the baby or the adult client). This may necessitate segregating the records or blacking out the information pertaining to the one whose records have not been requested.
- The charts of cases subject to investigation of any kind, a lawsuit or complaint to the college for example, should be kept separate from regular charts and not shredded if also electronically archived.
- Midwives may, but are not required to, respond to follow-up questions in certain circumstances. Midwives can provide general information (e.g., explaining abbreviations or deciphering difficult to read entries). A request for medical records is a request for what is actually in the record, and nothing more. Only if the authorizing request is stated very broadly and allows disclosure of any and all health information about an individual, may the midwife answer additional questions regarding PHI to the authorized party. Do not comment or hypothesize on the care provided.
- AOM On Call representatives are available for advice and support through the AOM office.
Organizations That May Make Requests
Children's Aid Societies
Children’s Aid Societies (CAS) may make verbal or written requests. Obtain a copy of the court order confirming that CAS has custody or legal guardianship, or a letter that confirms the CAS investigation. Keep in mind that prompt compliance is often important. Typically CAS can only request information about the infant, not the client. View our webinar Working with CAS (coming soon to our online store) to hear a lawyer explore these duties when a child may be at risk.
The Coroner has broad powers to investigate, including the power to seize records relating to a deceased person. The Coroner may use the police or physicians as agents to help investigate. Ask to see a written request or order from the coroner’s office and keep a copy.
Public Health Inspectors
Public health inspectors have the power to inspect premises and review records containing client information when investigating or following up on a complaint. Ask to see the public health inspector’s badge or identity card, and make a note of the name and number.
Police officers presenting a warrant must be given the information specified in the warrant and no more. Without a warrant, midwives can only provide PHI where there are reasonable grounds to believe that disclosure of information is required to reduce a significant immediate threat of serious bodily harm.
In the event of an adverse outcome, midwives may be approached by police for questioning, but the midwife is not obliged to speak with police. This holds true whether one is simply a factual witness, a person of interest or suspicion, or the target of a criminal investigation. Take time to rest and get advice from HIROC or AOM On Call representatives before responding.
A summons, subpoena or court order may also require that specific documents be given to the courts. It is important to understand how and to whom the documents must be given, and not to give them or discuss them except as required. For further information, see Being a Witness.
For further information, see Responding to requests for children's medical records on the CMPA website.