Informed consent, confidentiality, and record keeping
Informed consent, confidentiality, and record keeping
This domain tests the practical mechanics of consent, privilege, privacy, and records. Minnesota psychologists must obtain valid informed consent, protect confidential information, and maintain records that satisfy Board rules, the Minnesota Health Records Act, and HIPAA where applicable.
Core rules
- Informed consent should cover the nature of services, risks, benefits, alternatives, fees, confidentiality and its limits, and the client's right to withdraw. Consent is ongoing, not a one-time signature.
- Minors raise special issues: generally a parent or legal guardian consents, with developmentally appropriate assent from the child. In custody disputes, verify the custody order and who may consent and receive records.
- Confidentiality is broader than privilege. Privilege is an evidentiary rule held by the client; confidentiality is an ethical and legal duty. Exceptions include client waiver, abuse reporting, duty to warn, court orders, and some billing or supervision disclosures.
- Records must be accurate, timely, secure, and released only with proper authorization or legal requirement. Retain records per law, payer contract, and setting; minors' records often require longer retention.
Worked example
A parent with joint legal custody asks for the full therapy record of a 15-year-old. The psychologist should not release automatically. Verify the custody order, the adolescent's consent rights under Minnesota law, and the scope of the authorization. The psychologist may release only what is authorized, may discuss the adolescent's privacy interests, and must document the decision.
Traps that cost marks
- Treating a subpoena as a court order.
- Releasing the entire record when only a limited authorization exists.
- Ignoring a minor's developing autonomy.
- Promising absolute confidentiality.
- Destroying records while an investigation or litigation is pending.