Confidentiality and Anonymisation in Assessments & Clinical Portfolio

Maintaining confidentiality is a vital aspect of maintaining professional standards.  Common over-sights by trainees are the inclusion of identifying information in an appendix (e.g. name of service; identifying information of client or professionals involved), providing excessive information about client and family or geographic location. When writing, always ask yourself if you need to include that bit of information, and if so, is it possible to anonymise it more – for example:  X lived in a rural county rather than saying Somerset; a counselling service in the South West of England, rather than saying Checkpoint or Off the Record.

A brief statement in the introduction to case reports and other client-related assessments should make it clear that any names being used have been changed to protect the confidentiality of children and young people and their families/parents/carers.  Care should be exercised in anonymising documents included as appendices to reports and other written assessments, especially documents included in the clinical portfolio.  Any details that identify a child or young person or a parent/carer should be deleted or blanked out.  If using a felt-tip pen to blank out these details DO make sure that the details cannot still be read when the paper is held up to the light, for example. 

 

Other names and addresses (apart from the trainee’s own name and employing service for the clinical portfolio) should also be blanked out – e.g. names and addresses of GP surgeries.  Service details should NOT be identified at all for case presentations and case reports.  It is also good practice not to include information that might identify the author of assignments, such as details of their profession, for example.

 

Any breaches in confidentiality in any assessments will result in the assessment automatically being returned to the trainee for urgent attention, or will result in a fail if a serious breach – see below.

 

The following principles have been agreed as the process to follow where there are breaches in confidentiality in assessments submitted as part of the CEDAR PGT training programmes:

 

Case Presentations:

 

  1. With case presentations, no identifiable information should be presented on the client or the service.
  2. A minor breach in case presentations, where confidentiality/anonymisation has occurred and been acknowledged by the author, but then a minor mistake(s) gets picked up will be returned to the author for correction. The trainee will have 48 hours to reply and correct the errors in the presentation handouts, otherwise it will be marked as a fail.
  3. When major breaches are present or anonymisation has not occurred and/or been made explicit, this will be an automatic fail and the trainee would need to resubmit a second submission correcting the error (and making any other changes if there are other resubmission criteria).

 

Case Reports:

 

  1. In Case Reports there should be no identifiable information in relation to the client or service.
  2. A minor breach in Case Reports, where confidentiality/anonymisation has occurred and been acknowledged by the author, but then a minor mistake(s) gets picked up will be returned to the author for correction. The Trainee will have 48 hours to reply and correct the errors, otherwise it will be marked as a fail.
  3. When major breaches are present or anonymisation has not occurred and/or been made explicit , this will be an automatic fail and the trainee would need to resubmit a second submission correcting the error (and making any other changes if there are other resubmission criteria).

 

Clinical Portfolios:

 

  1. In the clinical portfolio, the trainee and the service can be identified but no identifiable information on clients should be included.
  2. If confidentiality breaches occur in a clinical portfolio in relation to clients, this will be marked as an automatic fail and the trainee will be asked to address the area of concern (and any other changes) for resubmission.