- Center for Ethical Practice - https://centerforethicalpractice.org -

Record Keeping: Focusing on the Ethical Underpinnings

In the midst of worrying about the record-keeping requirements imposed by state laws, HIPAA, managed care contracts, agency policies, etc., and with our eye on liability, are we losing our ethical perspective?  We will cover ownership, content, storage, retention time, and other practical issues, but our primary focus will be on the ethical considerations that should underlie our decisions.


I. Ethical Standards & Professional Guidelines

A. Does Your Ethics Code Contain The Answers You Need?

B. Where Else Do You Go for Ethical Advice About Clinical Records?

II. Legal Requirements

A.  Which Ones Apply To You?

B.  What Are Their Ethical Implications?

1. Virginia Licensing Board Regulations

2. State Agency Regulations

3. Virginia Health Records Privacy Statute – §32.1-127.1:03

4. Federal Regulations – HIPAA Privacy Rule & Security Rule

5. Federal Statute – Public Law 92-255 (re: substance abuse records)

6. Legally-Binding Contracts With Managed Care Organizations & Other Third Parties

III. Making Ethical Decisions About Content of Clinical Records

IV. Making Ethical Decisions About Process of Record Keeping

V. Making Ethical Decisions About Storage/Security/Retention/Destruction of Records

VI. Keeping The Focus Ethical

Educational Goals:
(a) List some of the ethical questions that are important to ask about your record keeping;
(b) Name some legal issues about record keeping that have ethical implications in your setting;
(c) Describe the ethical implications of your own decisions about content, retention, & destruction;
(d) Name your two biggest ethical or legal concerns about your own record keeping.