Value 6: Maintaining Privacy and Confidentiality

Context for Practice: Clinical specialists are entrusted with sensitive information that is pivotal to the therapeutic relationship. Ensuring confidentiality is crucial not only to maintain the trust of those receiving services but also to uphold the integrity of the social work profession. This commitment extends to all forms of communication and record-keeping.

Standards of Practice: Clinical specialists shall uphold confidentiality and protect the privacy of service users by:

6.1.1 treating all information obtained in the course of the clinical relationship as confidential, and using it solely for professional purposes;

6.1.2. being diligent in ensuring that professional interventions and information regarding service users are documented impartially, accurately, and with consideration for the potential viewing of these records by the service user or disclosure during legal proceedings;

6.1.3. ensuring service users have reasonable access to their official social work records in compliance with the Personal Health Information Act (PHIA).

Context for Practice: Clinical specialists respect the autonomy of service users in deciding if, when, and how their information is shared with others. The ethical management of this information is paramount to preserving the integrity of the therapeutic relationship and the professionalism of clinical specialists.

Standards of Practice: Clinical specialists shall seek informed consent before sharing information with third parties by:

6.2.1 informing service users about confidentiality in the therapeutic relationship and privacy of their record;

6.2.2 informing service users of the nature of any requests from third parties to have access to the service user’s record and limits of any disclosure;

6.2.3 seeking written consent by service users prior to releasing any information unless required by law or court order;

6.2.4 exercising caution to protect the confidentiality of others when giving service users access to records, which may include the redaction of third-party information from the record as necessary;

6.2.5 implementing suitable precautions to protect service user confidentiality in cases of the clinical specialist’s termination of practice, incapacity, or death.

NSCSW Social Work Documentation Guidelines.³

Context for Practice: Clinical specialists are obligated to maintain documentation that accurately reflects the services provided. This involves systematic, clear, and comprehensive written or electronic recording practices that ensure the integrity and confidentiality of service user information while upholding professional standards and ethical responsibilities. Clinical specialists take precautions to ensure privacy and confidentiality in the provision of electronic clinical social work services.

Standards of Practice: Clinical specialists shall maintain accurate and comprehensive records of service user interactions by:

6.3.1. regularly documenting, within the service user’s file, progress notes, reports, and summaries of service user interactions. These records must align with NSCSW guidelines, ensuring that documentation practices support both accountability and confidentiality;

6.3.2 ensuring that professional interventions and information regarding service users are documented impartially and accurately, recognizing that these records may be accessed by the service user or may need to be disclosed during legal proceedings.