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Inappropriately accessing client records

Is it worth the risk?

What would you do?

Nurse A: Did you hear? That new nurse Carol was admitted overnight.

Nurse B: I wonder what she’s in for. I think I’ll take a quick peek at her record

Nurse A: What!? You can’t do that!

Nurse B: Sure I can. I work here, don’t I?

BCCNM regularly receives complaints about nurses and midwives inappropriately accessing client records. This includes accessing records for clients not in their care, or for reasons other than providing care.

This behaviour is unprofessional and inappropriate, and could result in:

  • Loss of your reputation, job, or career
  • College disciplinary action
  • Legal actions against you

Access to a client’s health-care record is restricted to care providers who are involved in the client’s care (often called the client’s circle of care). Just because you are a health-care professional doesn’t automatically mean you can or should access any client record.

This means you do not access the records of family members, friends, colleagues, or clients with “interesting” diagnoses, or “famous” people, or other clients on the unit or in your workplace, unless you are involved in their care.

For example, if you are covering another nurse’s clients during a break, you become part of the client’s circle of care and are authorized to access the client’s record but only for purposes that are consistent with your professional responsibilities.
Workplaces track who accesses client records. If they find that you have accessed the records of clients with whom you have no professional nursing relationship and have no need to access, they can take action as per their workplace policy.

Family & friends

If a family member or a friend asks you to look at their record, unless you are part of their circle of care you are not authorized to access their record, share, or disclose their personal health information.

Whenever possible, nurses are expected to take steps to ensure they are not providing care for family or friends, though this can be difficult in small communities. Doing otherwise is a breach of BCCNM standards and workplace policy and can result in disciplinary action.

Accessing my own records as a health-care professional

Under B.C. law the information included in your health-care record belongs to you. However, even though the information belongs to you, the physical or electronic records don’t; they belong to whoever created them—for example, a physician, a hospital, or midwife. You must follow the steps outlined by the owner of the record to gain access or request a copy of the record. Accessing your records outside of these approved channels is a breach of BCCNM standards and workplace policy and can result in disciplinary action.

Ensuring security of client information

Nurses and midwives have a professional responsibility to act if they see or know of an unauthorized person accessing client records. An unauthorized person can include colleagues or other care providers who access the client’s record for purposes that are not consistent with their professional responsibilities. 

If someone who is not part of the client’s circle of care asks you to look up information in a client’s record, explain to them that to protect client privacy and confidentiality:

  • You are not authorized to access client record as you are not part of that client’s circle of care, and it is a breach of BCCNM standards and workplace policy.
  • You are not authorized to share client information with those who are not part of the client’s circle of care as it is a breach of BCCNM standards and workplace policy.

Follow workplace policies, or report to the appropriate regulatory college if you find others have inappropriately accessed or disclosed a client’s personal or health information.

See the consequences of unauthorized access to client records: