This article was first published in the January 2024 Communiqué
Language of Records
Previously, the standards expected records to be maintained in English or French. In response to feedback and the diversity of Ontario, the commentary to Standard 5.1: Clinical Records, now recognizes that progress notes may be recorded in the language in which therapy is taking place. The standard expects that key information, which includes the client profile and anything else, such as a summary, which needs to be readily accessible to other healthcare providers in an emergency, be in English or French.
Access to Joint Therapy Records
Standard 5.1 now contains commentary on providing access to joint therapy records, such as for couple, family, or group therapy. Clients may access the entire record if all participants consent or submit a joint request (e.g., both members of a couple request access to the couple therapy record). If only one participant requests access to a joint record, and the others have not consented, they are only entitled to the information about themselves, and any communal information (e.g., general themes) that is not attributable specifically to another participant.