Help with redacting client records

August 5, 2010
5 Comments

A couple of weeks ago, I spoke with a reader who was seeking help or guidelines for redacting client documents. He works as a quality/procedures manager with a children's services agency and frequently is ordered to hand over records for various legal proceedings, including child custody hearings and foster care placements.

While he wishes to provide the most reliable and important information about the child in the child's record, he feels obligated to redact certain information about the child's parents or caregivers, such as their reported substance use problems, reported history of treatment, accusations of neglect/abuse, etc. He sought advice from other local providers, but was unable to get what he was looking for. Do any of you out there have any suggestions or guidelines for redaction? How do you handle or redact factual—or questionable—information regarding a client or a client's relatives?

I'd love to tackle this in an upcoming article and look forward to your thoughts.

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Hi, this is a very

Hi, this is a very interesting article and I have enjoyed read­ing many of the arti­cles and posts con­tained on the web­site, keep up the good work and hope to read some more inter­est­ing con­tent in the future. I got a lot of useful and significant information. Thank you so much.

Some of the guidelines we use at our facility:

If copies of records are going to the consumer and the consumer is the only person participating in treatment then no information should be redacted.

If copies of records are going elsewhere, then individual names, other than the consumer, or licensed professional, should be redacted. Exp: Jo's grandmother, Mary Smith, has a history of depression. You would redact Mary Smith.

If copies of records are going to the PCP or another mental health provider, only redact personal names & drug & alcohol, if not authorized.

If drug and alcohol information is not covered on the release and information regarding drug and alcohol abuse is in the record about others (verify if others not consumers at organization). If unable to verify or know that others are not consumers and the information is going to consumer, then no information should be redacted.

Court orders must be followed exactly as instructed. No information may be redacted in a court ordered release of information.

(Court orders and Subpoenas are two different legal requests. Court orders are signed by the Judge & Subpoenas are signed by an attorney. Judges have the ability to order records but the attorneys requesting the order must go through the proper court process otherwise we do not act on their orders we send a motion to reconsider to the Judge.)

Drug & alcohol abuse and Communicable disease records may only be released with the individual's written authorization. If the attorney in the last statement did not go through the proper court process, this would be a reason to request the Judge reconsider the Order.

Your post is so interesting

Your post is so interesting and informative. I got a lot of useful and significant information. Thank you so much.

Redacting records

Our private, not-for-profit, community behavioral health organization only releases information by way of Court Order or by way of a valid, current Release of Information signed by parent/guardian for under age 18, or by the client when age 18+. Even with a Court Order or Release, we redact all 3rd-party specific information related to AoD, mental health, HIV/AIDS and other protected health information not specifically relevant to the identified client. The Court may order release of all info regarding the child but that is NOT inclusive of Uncle Joe being seen at an adult treatment agency for drug issues and depression. At minimum we would redact a name. However, we often redact the entire statement if we are not confident that the person's identity will be protected. For example, we would not leave a statement indicating "mother", even sans her name. We have worked closely with our courts and Department of Jobs and Family Services in order to be helpful in providing needed information while following the law.

Redacting records

Our private, not-for-profit, community behavioral health organization only releases information by way of Court Order or by way of a valid, current Release of Information signed by parent/guardian for under age 18, or by the client when age 18+. Even with a Court Order or Release, we redact all 3rd-party specific information related to AoD, mental health, HIV/AIDS and other protected health information not specifically relevant to the identified client. The Court may order release of all info regarding the child but that is NOT inclusive of Uncle Joe being seen at an adult treatment agency for drug issues and depression. At minimum we would redact a name. However, we often redact the entire statement if we are not confident that the person's identity will be protected. For example, we would not leave a statement indicating "mother", even sans her name. We have worked closely with our courts and Department of Jobs and Family Services in order to be helpful in providing needed information while following the law.