Date of Last Review 9/17/10
Date
of Last Review 10/07/10
SME: Director of Health Information Management
The UTHCPC patient has a right, within the limits of the law, to personal privacy
and confidentiality of information. The information contained in the medical
record belongs to the patient; however, the medical record itself belongs to
UTHCPC.
All known information in the hospital about an inpatient is considered strictly confidential, including the following:
 | Name |
| Address |
| Gender |
| Age |
| Occupation |
| Admission/discharge dates |
|
Medical Record number PNO (billing number)
|
Each patient has a right to access information in his/her record and, with some exceptions, to control who else receives the information.
A written consent authorization to release confidential patient information is required before releasing any patient information. The release must be renewed after 90 days.
The following exceptions do not require a written consent authorization:
Exception |
Description | ||||||
Court-ordered examination |
The court is responsible for the following:
| ||||||
Medical emergencies |
Clinical staff can disclose relevant information in the following conditions:
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Patient physically incapacitated |
A patient is considered physically incapacitated in these situations:
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Other agencies |
Some agencies are entitled by law to confidential information. Example 1: Texas Department of Family and Protective Services can obtain information when investigating child or adult abuse. Example 2: When a patient transfers from UTHCPC to TXMHMR facility or one of their designated providers, the new facility can obtain information. Example 3 : Neuropsychiatric Center (NPC) Note: After hours contact the Nursing Supervisor and/or Administrator on-call for a determination regarding the release of patient information for requests from other agencies not specified above.
| ||||||
Civil process |
Attorneys who are representing the patient in the civil commitment process can access the patient's information. |
The patient's chart must contain current information about the person who is authorized to release information. The completed Release of Information form is placed in the patient's chart.
In the following situations, someone other than the patient can authorize the release of confidential information:
When the patient is... |
Information release can be authorized by ... |
||||||||
Legally declared mentally incapable |
The guardian |
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A minor under 16 years of age and receiving mental health services |
|
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A minor age 16-18 and voluntarily receiving mental health services |
|
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A minor age 16-18 and receiving court-ordered mental health services |
|
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| Juvenile Probation | Patient records belong to the Juvenile Probation Division. Permission to release patient information must be obtained from Juvenile Probation designee. There must be a proper completed authorization form in place. |
If someone wants to authorize the release of information, s/he must fill out a Authorization to Release Medical Information form (see reference, Authorization to Release Medical Record Information form) including all the following elements :
| Identification elements |
 | The name of the patient |
| The name of the facility that will release the information |
| The name of the facility or person that will receive the information |
| Agreement elements |
| A specific description of the information |
| A statement of the ability to revoke the authorization at any time |
| The expiration date or conditions that will end the authorization |
| Authorization elements |
| The signature of a person who has the authority to consent or release information |
| The date of the authorization |
| Patient's date of birth |
| Patient's social security number |
| Substance abuse/HIV patient elements |
| A statement about why the information is needed and how it will be used |
| A statement explaining that the receiving person or facility cannot disclose the information without additional written consent from the patient or someone authorized to sign for the patient |
The following conditions of the consent or authorization prevent the release of information:
| Does not contain all the elements |
| Is coerced |
| Might contain false information |
The Health Information Management (HIM) department answers the request for information releasing.
An employee prepares a request for information release as follows:
| Determines who is currently legally responsible for signing the Release of Medical Information form |
| Makes certain that the completed form has all of the information required |
| Hand-delivers the completed form to HIM department |
Medical records may be accessed after hours in the HIM department by authorized personnel such as:
| Physicians |
| Nursing supervisor |
Access: Follow the steps below to enter the HIM department:
| Retrieve the key from the Nursing Supervisor's office |
| Sign your name, date, and time in the key log out book |
| Upon completing your records review, return the key to the Nursing Supervisor's office and log the time you returned the key |
Authorization
to Release Medical Record Information
Authorization to Disclose
Patient Information
If you have questions regarding the contents of this site please contact the
Policies and Procedures Committee.
If you experience any technical problems please contact the MIS Department..
