HIPAA Privacy Training for
Students:
A Self-Study Module
Matrix of
Developed by the
HIPAA Readiness Collaborative
June 2005
FACILITY NAME: Alcoholic Rehabilitation Services of Hawai‘i, dba Hina Mauka
|
SPECIAL CONSIDERATIONS
FOR PATIENT PRIVACY |
In addition to HIPAA, the strict confidentiality of
records of persons receiving alcohol and drug prevention and treatment
services is protected by Federal law, implemented through Federal regulations
42 C.F.R. (Code of Federal Regulations), Part 2. Noteworthy provisions: -
Prohibits disclosures except with client consent (or 9 other specific
conditions). -
Prohibits re-disclosure except with explicit signed
consent/authorization. This differs
from HIPAA. -
Allows limited disclosure for payment, evaluation, and other purposes
with Business Associate Agreements. |
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
No directory is maintained for general/public
use. |
|
FACILITY DIRECTORY ·
Where is patient's information status
documented? |
Originals are found in the client clinical
record. Generally, unless a signed
consent/authorization to release information is found, we are not permitted
to contact family. Treatment Associates office maintains a directory of
clients and copies of signed consent/authorization for release of information
to specific persons making inquiry.
Reception desk, the usual first receiver of visitors and telephone
inquiries, is also provided with a copy of consent forms as applicable. |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
In the client
clinical record. Generally, unless a
signed consent/authorization to release information is found, we are not
permitted to contact family. Also,
Reception Desk and Treatment Associate staff, who
are first receivers of visitors and telephone inquiries, are notified of
client’s objection through a memo from counselor or through daily census
meetings. |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
In the client clinical record. Generally, unless a signed
consent/authorization to release information is found, we are not permitted
to contact family. Also, Treatment
Associate staff are notified through a memo from counselor
or through daily census meetings. |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
This information is not currently available. Information will be available to students
prior to their placement at Hina Mauka. |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Psychiatry residents may contact Medical Director,
program director or designee. R.N. or
any counselor may assist in locating PHI in the client record for any client
currently being seen by a psychiatry resident. For non-active cases, contact custodian of
records. |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
Signed consent/authorization by the client is
required. Consent must meet standards for 42 CFR, pt. 2. as
well as HIPAA. |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
Contact Hina Mauka’s Privacy Officer and IRB chair. |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
For disclosures from active clinical records, the
clinician making the disclosure records the fact in the client record. For
non-active clients, the custodian of records documents disclosures. Disclosures of financial information are
documented in a running record/log by staff making the disclosures. |
|
PRIVACY TRAINING REQUIREMENTS |
All staff are provided with Confidentiality and
Privacy Training, covering both 42 CFR, Part 2; and
HIPAA; upon hire or (for volunteers and students) job assignment. |
FACILITY NAME: Clinical Laboratories of
* Operates labs in following hospitals: Straub, both
Kapiolani Medical Centers, both
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
N/a |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
N/a |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
N/a |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Billing
Department |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Privacy Officer |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
Submit written
request stating purpose is treatment |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
Privacy Officer |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Privacy Officer |
|
PRIVACY TRAINING REQUIREMENTS |
Will accept HRC
training for residents |
FACILITY NAME: Diagnostic Laboratory Services, Inc. (DLS)
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
N/A N/A |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
N/A |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
N/A |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
“Restriction
Request Forms” and their disposition maintained by the DLS Privacy Officer. |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes, check with
DLS Privacy Officer. |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
DLS Privacy
Officer. |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
DLS
will release PHI to other providers for treatment purposes after verifying
the identity of the requestor and the authority to receive PHI. |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
DLS Privacy
Officer. |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Automated
computerized accounting for most disclosures (DOH). Manual (Ad Hoc) accounting for others
(subpoenas etc.) Computerized
tracking and documentation accessible by Privacy Officer. |
|
PRIVACY TRAINING REQUIREMENTS |
DLS
accepts HRC’s standardized community Training Program. |
FACILITY NAME:
|
SPECIAL CONSIDERATIONS FOR PATIENT PRIVACY |
HSH IS A
PSYCHIATRIC FACILITY AND IS REQUIRED TO COMPLY WITH SPECIFIC JCAHO, DOJ, AND
DOH REQUIREMENTS. |
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
IN PATIENT
CHART TELECOMMUNICATIONS |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
IN PATIENT
CHART |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
IN PATIENT
CHART |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
IN PATIENT
CHART |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
YES |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
CAROLYN
TAKAHASHI, ACTING CHIEF OF MEDICAL RECORDS |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
MEDICAL RECORDS |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
RYAN MCMULLIN,
PH.D. |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
ALL PATIENT
CARE STAFF IN PATIENT
CHART |
|
PRIVACY TRAINING REQUIREMENTS |
FILM IN STAFF
DEVELOPMENT |
|
OTHER |
PRIVACY OFFICER
IS RUTH STEWAT, RN, MS, CPHQ, CHIEF OF STANDARDS AND COMPLIANCE |
FACILITY NAME:
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
1.
Regular information—location only. 2.
No information. Condition is
given by nursing staff only. |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
Hospital
Information System (McKesson) and on the Consent to Release to the Public
form in the patient’s record. |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Release is
permitted unless the patient has completed a Request for Restriction form. |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
On the Request
for Restriction form in the patient’s medical record. |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Medical Records
Department |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
Medical
Records Department |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
Privacy Officer |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Medical Records
Department |
|
PRIVACY TRAINING REQUIREMENTS |
Record of
completion of HIPAA training. |
FACILITY NAME:
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
STATUS: 1.
Regular info 2.
No info |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
Hospital
Information systems: SMS |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Release okay
unless patient has made specific objections.
Would be documented in the medical record
|
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Restriction
Request form in the medical record |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes – refer to
Policy regarding Educational Uses of PHI |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Medical Records
for medical information; Business
Services for billing records; Medical
Records, ORSOS system administrators for data reports Note: Data Access Request form
Required |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
PHI may be released for treatment purposes in response to any of the
following 1.
Patient authorization 2.
Letter from physician practice, 3.
Provider Request for Information
form or similar document |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
IRB or Privacy
Officer |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? ·
Where and how are disclosures
documented? |
·
Each individual is responsible for
documenting disclosures. All documentation is kept in the chart. ·
Documentation forms are available on
each unit. Check with Supervisor of
area to see what their procedure is. Centralized Collection points: 1.
Medical Records for Medical records;
2.
Business services for billing
records |
|
PRIVACY TRAINING REQUIREMENTS |
Completion of HPH HIPAA training requirements for
direct access or HRC’s standardized
community Training Program |
|
OTHER |
Contact Privacy Officer |
FACILITY NAME:
|
FACILITY
DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
STATUS: 1.
Regular info 2.
No info |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
Hospital
Information systems: SMS and Karelink |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Release okay
unless patient has made specific objections.
Would be documented in the medical record
|
|
OTHER
RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Restriction
Request form in the medical record |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes – refer to
Policy regarding Educational Uses of PHI |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Medical Records for medical information; Business
Services for billing records; Medical
Records, Karelink or ORSOS system administrators for data reports Note: Data Access Request form Required |
|
REQUEST FOR PHI
BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
PHI may be released for treatment purposes in response to any of the
following 1.
Patient authorization 2.
Letter from physician practice, 3.
Provider Request for Information
form or similar document |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
IRB or Privacy
Officer |
|
ACCOUNTING OF
DISCLOSURES ·
Who is responsible for accounting of
disclosures? ·
Where and how are disclosures
documented? |
·
Each individual is responsible for
documenting disclosures. All documentation is kept in the chart. ·
Documentation forms are available on
each unit. Check with Supervisor of
area to see what their procedure is. Centralized Collection points: 1.
Medical Records for Medical records;
2.
Business services for billing
records |
|
PRIVACY
TRAINING REQUIREMENTS |
Completion of HPH HIPAA training requirements for
direct access or HRC’s standardized
community Training Program |
|
OTHER |
Contact Privacy Officer |
FACILITY NAME: Kuakini Health System
|
SPECIAL CONSIDERATIONS FOR PATIENT PRIVACY |
This response applies to acute care and long term care inpatients.
Patient privacy issues are discussed at registration and special requests are
flagged in the computer system. |
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
This response applies to acute care and long term care inpatients.
Patient privacy issues are discussed at registration and special requests are
flagged in the computer system. If the
patient request that they not be included in the facility directory, their
request is flagged in the computer and forwarded to the receiving floor. The hospital operator will not have that
patient’s name on the directory at all. |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
This response applies to acute care and long term care inpatients.
Patient privacy issues are discussed at registration and special requests are
flagged in the computer system. If the
patient request that they not be included in the facility directory, their
request is flagged in the computer and forwarded to the receiving floor. The hospital operator will not have that
patient’s name on the directory at all. |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
This response applies to acute care and long term care inpatients. Patient privacy issues, including the
identification of a PRIMARY individual to disclose protected health
information are discussion during registration. The information gleaned is flagged in the
computer system. |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
This response
applies to acute care and long term care inpatients. Patient privacy issues
are discussed at registration and special requests are flagged in the
computer system. |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes for both
acute care and long term care inpatient within specified guidelines. |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Medical Records |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
Medical Records |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
Robin Miyamoto,
Research Coordinator |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Medical Records Tracked by the
computer system. |
|
PRIVACY TRAINING REQUIREMENTS |
Record of education on HIPAA. Signature on the Confidentiality
form. |
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
Front Desk Each Nurses
Station |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
Front Desk Medical Record |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Medical Record |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Front Desk Medical Records
|
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Medical Records |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
Medical Records |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
Medical Records |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Medical Records |
|
PRIVACY TRAINING REQUIREMENTS |
HRC Privacy
Training & Signed Confidentiality Agreement |
FACILITY NAME:
|
SPECIAL CONSIDERATIONS FOR PATIENT PRIVACY |
Long term care
and acute TB unit |
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
Regular No Information Noted in chart,
computer system, internal directory |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
Noted in chart,
computer system, internal directory |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Noted in chart,
computer system, internal directory |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Noted in chart,
computer system, internal directory |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Medical Records |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
Medical Records |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
HIPAA Officer-
Administration |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Medical Records |
|
PRIVACY TRAINING REQUIREMENTS |
HRC Privacy
Training & Signed Confidentiality Agreement |
FACILITY NAME:
The Queen’s Medical Center (QMC)
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
1.
Regular info- location and condition
2.
Limited info – acknowledge patient
is at QMC only 3.
No info 4.
Pending- Trauma/VIP pt. No info to public while trying to notify
family and determine status |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
Hospital
Information System (SMS) Patient Care
Summary |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Release okay
unless patient has made specific objections.
Would be documented in the medical record |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Refer patient
to the Privacy Officer |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
-
Medical Records for charts and
copies -
IS help desk for access to computer
systems -
Data Coordinator of system for data
queries and reports |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
-
Okay to release if treatment
relationship documented -
If not documented, Licensed health
care provider (MD or RN) will accept
patient authorization, letter from physician practice, Provider
Request Form |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
QMC Research
Regulatory Office at 808-547-4512 |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Through
computerized computer entry system – CLiQ |
|
PRIVACY TRAINING REQUIREMENTS |
Satisfactory
completion of Collaborative’s Privacy Training Session |
|
OTHER |
Students may
not remove documents containing PHI from facility. See Privacy Officer for approval and
de-identification. |
FACILITY NAME:
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
Regular
information No information
(NOI) |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
Hospital
information system (Affinity) Medical record
chart cover : NOI sticker |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Family contacts
listed on Face Sheet Objections are
recorded in chart: Discharge Plan
Screening form in Case Management section |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Medical record |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
For medical
record: Clinical Information Dept (CID) For electronic
access: Information Systems Dept (IS) |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
May release for
treatment after verification of requesting provider’s involvement in
patient’s care (verification form) |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
Research,
Education, and Training Dept (RET) |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Clinical Information
Dept (CID) Disclosures are
documented in the medical record by person making the disclosure |
|
PRIVACY TRAINING REQUIREMENTS |
Either REHAB
privacy orientation or HRC Privacy Training |
FACILITY NAMES: St. Francis Medical Center & St. Francis Medical Center-West
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
1.
Regular Information 2.
No Information |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
Hospital
information system (SMS). Confidential"
header on patient's Face Sheet. Direct visitors
to Information Desk or Operator who will check the Secure Census. |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Permissible
unless patient has requested to restrict family involvement. Patient's request and facility decision are
documented on the Restriction Request form in the medical record. |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Restriction
Request form in the medical record |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Health
Information Management department for medical records Business Office
for billing records Information
Services Help Desk for data queries or reports |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
Permissible if
treatment relationship is documented within hospital information system, or
with patient authorization, Provider Request form, or fax / letter from other
healthcare provider. |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
Privacy Officer
|
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Each program,
service, department or facility is responsible for documenting disclosures,
and making such documentation available to the Privacy Officer upon request. |
|
PRIVACY TRAINING REQUIREMENTS |
Satisfactory
completion of HRC or SFHS privacy training program |
|
OTHER |
Procedures are similar for St. Francis Hospice and St. Francis Home
Care Services |
FACILITY NAME: Straub Clinic and Hospital
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
STATUS:
|
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
Hospital
Information system - IDX |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Release okay
unless patient has made specific objections.
Would be documented in the medical record
|
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Restriction
Request form in the medical record |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Medical Records
for medical information; Business
Services for billing records IT for reports Note: Data Access Request form Required if not
for TPO |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
|
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
IRB or Privacy
Officer |
|
ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
Centralized
Collection points:
Each individual
is responsible for documenting disclosures. All documentation is kept in the
chart. Each area has different
approach. Check with Supervisor of
area to see what their procedure is. |
|
PRIVACY TRAINING REQUIREMENTS |
Completion
of HPH HIPAA training requirements for direct access or HRC’s standardized community Training
Program |
|
OTHER |
Plastic Surgery
Records kept separate from Medical Records; See Privacy Officer |
FACILITY NAME:
|
FACILITY DIRECTORY ·
Patient Info Status ·
Callers or Visitors |
1.
Regular info 2.
No info |
|
FACILITY DIRECTORY ·
Where is patient's information
status documented? |
No info
patients have a plus sign (+) noted to the right of their names on the CPSI
information system. |
|
FAMILY INVOLVEMENT ·
Where is patient's objection to
family involvement documented? |
Persons whom
staff may contact and/or speak with are listed on the Face Sheet. |
|
OTHER RESTRICTION REQUESTS ·
Where is patient's restriction
request (and facility's decision) documented? |
Request for
Restriction form |
|
FACIALLY DE-IDENTIFIED INFORMATION ·
Does facility permit use of facially
de-identified PHI for educational purposes? |
Yes |
|
ACCESS TO PHI ·
Whom should I contact if I need to
request access to PHI? |
Medical Records
Department |
|
REQUEST FOR PHI BY OTHER HEALTH CARE PROVIDERS FOR TREATMENT PURPOSES |
Patient
authorization is required. |
|
RESEARCH ·
Whom should I contact if I need more
information about requirements for research? |
Privacy Officer |
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ACCOUNTING OF DISCLOSURES ·
Who is responsible for accounting of
disclosures? Where and how are
disclosures documented? |
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PRIVACY TRAINING REQUIREMENTS |
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