What to Write When You Break Confidentiality

Most of us have been there... that uncomfortable moment when your client is talking about something you know you'll need to report. Even if you've had the unfortunate experience of doing this multiple times, it still causes an unsettling feeling of uncertainty.

Part of that uncertainty comes after the situation is reported and over... when you sit down to write your notes. How much do you write? What do you need to include? What do you want to avoid writing? Will this note cover your butt?

There are a few things you always want to include in your note for that session and a few things you don't want to put in your note. The key here is that you want to provide your rationale for why you broke confidentiality but you don't want to include all the details of the incident itself. 

Include the following:

  • The general reason you needed to break confidentiality (example: client reported an incident of child abuse)
  • Limited details to support this claim (example: client reported her husband beat their son after performing poorly in a sporting event and her son has multiple visible bruises)
  • Your method of reporting the incident (phone call to protective services, online reporting system, etc.)
  • The name of the person you talked with while making the report
  • Any confirmation/reporting number you receive as a result
  • Appropriate plan for follow-up as needed
  • Whether or not you consulted with any colleagues regarding the report and their recommendations

Avoid the following:

  • Further details of the incident- this information should be kept confidential so leave the details to your required reporting form
  • Copies of any reporting forms- keep these in a file separate from your client's personal files

Following these principles should make you feel confident that if anyone reviewed your records they would understand why you needed to break confidentiality to report the incident. They would know that you acted ethically and clearly understand your responsibility. However, they wouldn't be able to recreate an entire play by play of the incident.

As is always the case with confidentiality, provide only the information necessary. Crises and mandated reporting do not give you a free pass to share any and all information. Stick with what is necessary and when in doubt, consult with a trusted colleague. You can even review your note with a colleague to see if they are able to clearly identify why you needed to break confidentiality. Then, engage in an act of self-care! These situations are stressful and take a toll if you don't care for yourself and get the support you need. 

If you'd like more tips on writing notes and keeping your license safe, sign up for my monthly newsletter (and get access to my free Paperwork Crash Course). I send out extra tips and resources and then you'll never miss another helpful blog post! Happy (and ethical) writing to you!!