Health Information Compliance Alert

Question: How should we label a chart when an adolescent confides in the pediatrician about sex/drugs but does not want the parent to know? We have a few patients between the ages of 15 and 17 who have requested confidentiality and I know there are laws protecting them but am uncertain how we maintain the privacy of minors?

Answer: The legality of confidentiality for minor patients will depend on individual state law. If you are counseling a patient on substance abuse, mental health, contraceptives, or other issues, some states require parental consent before you treat the patient.

In other states, however, minors can consent to treatment for these and other problems, so as long as you are within the law, you can keep the records confidential. For instance, if the law in your state specifies that at age 16 minor patients can maintain confidentiality when discussing contraceptives, then if the chart is copied to give to the parents, confidential information must be withheld, unless the child gives express permission at the time. Sometimes offices have a separate component in the record for confidential visits.

Keep in mind: If the child is endangering himself or others, document and report it to the necessary authorities as prescribed by your state laws or licensing regulations.

If the child is not a danger to himself or others and you are legally permitted to maintain confidentiality, you can document "DO NOT COPY OR RELEASE TO PARENTS" on the chart, the individual records, and/or the electronic files. In addition, some physicians keep such documentation separate from the main chart in a confidential folder.