Confidentiality of Records and Files Pertaining to Medical Staff

Introduction

Date of Last Review 3/13/06
SME: Dr. Andrew Harper

UTHCPC medical staff recognizes the importance of maintaining the confidentiality of medical staff records for both legal and policy reasons.

Policy

UTHCPC only permits the disclosure of medical staff records under the conditions described in this policy.

Definition: medical staff records

The following items are confidential medical staff records and protected from disclosure:

All credentials files and all information contained therein

All reappointment information including monitoring and reevaluation material

All medical staff committee and subcommittee minutes, documents, and appendages

All medical staff performance improvement minutes, documents, and appendages

Individual peer review activity files and all correspondence and committee minutes pertaining thereto

Reference: See:

Section 161.032 of the Texas Health and Safety Code

Article 160.007 Texas Occupations Code

Maintenance

Who
The Medical Staff Coordinator or designee maintains all confidential medical staff records.

Where
S/he maintains these records in locked file cabinets in the medical staff services office.

Legal issues

Subpoenas
The Executive Director consults with the Medical Director, President of the Medical Staff and the legal counsel before responding to all subpoenas for medical staff records and files.

Open records requests
Legal counsel handles all open record requests for information in the medical staff records.

Access	This table provides information about access to confidential medical staff records: Restrictions: The Medical Staff Coordinator unlocks the file cabinets only when s/he, or his/her designee, is physically present and able to monitor access to the files. Persons permitted access to the records may inspect the records and take notes, but may not remove or make copies of the records. All electronic data is encrypted on the server and protected in a secured room. All electronic data s limited to role based accessibility.
	Access to...	Approved by...	Conditions of Disclosure
	Appropriate parties performing official hospital or medical staff functions	President of the Medical Staff or Medical Director or Executive Director	Person permitted access has a reasonable opportunity to inspect the records in question and make notes regarding them
	Outside agencies	Executive Director after legal counsel evaluates the request	UTHCPC notifies the individual practitioner when the request is for information contained in the credentials file
	Practitioner	N/A	Access to documents in his/her own credentials file that s/he submitted Initial application Reappointment application Delineation of privileges Correspondence from him/her or addressed/copied to him/her
	Practitioner submitting written request	Medical Staff Executive Committee or designee	Access to: Any further information in his/her credentials files Peer review activity file
	Regulatory agencies	N/A	Access to credentials files for verification of: Current licensing Liability insurance Board certification

Routine credentials request process	This table describes the routine credentials request process:
	Stage	Person Responsible	Description
	1	Another hospital	Requests routine credentials information about a practitioner.
	2	Practitioner	Signs and submits a statement authorizing the release of the information to the requesting hospital.
	3	Medical Staff Coordinator	Gathers the appropriate information from the practitioner's credentials file.
	4	Medical Staff Coordinator	Writes a response to the request and submits it to the Medical Director or the Executive Director.
	5	Medical Director or Executive Director	Reviews and signs the response to the request.
	6	Medical Staff Coordinator	Sends the response to the requesting hospital.

Related standard

Related to regulatory standards

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