Date
of Last Review 5/6/08
SME: Director of Health Information Management
At UTHCPC, a patient's right to confidentiality of information regarding his/her
case is well accepted. UTHCPC respects and actively works to protect this right.
During new employee orientation, UTHCPC personnel sign a staff standard of practice and behavior document as well as a confidentiality statement. They also receive training regarding patient confidentiality and ethics.
The new employee learns the following during his/her orientation:
 | The employee responding to telephone inquiries or individuals presenting in person should state the following: |
 | S/he is legally prohibited from providing any information about any patient at UTHCPC. |
| S/he asks the individual to leave his/her name and telephone number, and the employee will investigate to determine if the person in question is a patient at UTHCPC. |
| If the person in question is a patient at UTHCPC, s/he will inform the patient. |
| All patients unless adjudicated incompetent will be asked to sign the Authorization to Disclose Patient Information form. |
| Employees cannot disclose the patient's presence or absence to relatives prior to written authorization from the patient. |
This table describes Patient Registration's role in protecting a patient's information upon admission:
Stage |
Description | |||||||||||||||||||
1 |
The staff provides an explanation and presents the patient with the Authorization to Disclose Patient Information form to sign. | |||||||||||||||||||
2 |
The staff asks the patient for names of people who are allowed to contact him/her while hospitalized. | |||||||||||||||||||
3 |
This table describes what happens when the patient signs or does not sign the form:
| |||||||||||||||||||
This table describes what security/front desk does when a patient receives a visitor, flowers, or mail:
Stage |
Description | ||||
1 |
Security signs visitors in and sends them to the Reception desk. | ||||
2 |
Reception (front desk) contacts the nursing units to verify if the patient wants to receive visitors, flowers, or mail. | ||||
3 |
Nursing staff informs the patient of the request. | ||||
4 |
Does the patient want to receive anyone or anything?
| ||||
5 |
When no staff are assigned to work at the Reception desk, Security contacts the Nursing Supervisor to handle inquiries. |
This table describes what the telephone operator does when s/he receives a call regarding a patient:
Stage |
Description | ||||
1 |
The operator tells the caller s/he will see if the person is a patient at UTHCPC. | ||||
2 |
The operator calls the nursing units to verify if the patient has given permission to receive telephone calls from the caller. | ||||
3 |
Has the patient given permission?
|
The Nursing staff makes every effort to protect identifying information on a patient's chart from visitors. This table describes how Nursing protects a patient's information from persons calling the Nursing unit directly without going through the Operator or visiting the unit:
WHEN the unit... |
THEN the Nursing staff... | ||||
Receives a direct telephone call |
Asks the patient if s/he wants to receive the call
| ||||
Receives a visitor |
Consults the patient whether s/he wants to receive the visitor
|
If the patient's treatment requires collaboration on the patient's behalf with community agencies, Social Services executes a specific Authorization to Disclose Patient Information form early upon admission.
This table describes how the social service clinician protects a patient's information:
Stage |
Description | |||||||||||||||||||||
1 |
The clinician obtains the patient's authorization to involve family, significant others, and appropriate community agencies in the medical record. | |||||||||||||||||||||
2 |
The clinician receives telephone and/or face-to-face inquiries from persons whom the patient has given consent for their involvement in the treatment. | |||||||||||||||||||||
3 |
This table describes how the clinician responds to inquiries and patient refusal of signing an Authorization form:
| |||||||||||||||||||||
The Health Insurance Portability and Accountability Act (HIPAA) is a set of federal regulations intended to give patients more control over their medical records and to ensure that patients in all states are guaranteed certain rights. For questions regarding HIPAA standards, contact the Privacy Officer at 713-741-8612.
| Right to Notice - UTHCPC's Notice of Privacy Practices explains all of the ways we typically disclose patient information and is available upon request in Patient Registration |
| Right to Restrict Disclosure - If a patient asks for a reasonable restriction on disclosure of information, UTHCPC will generally agree to abide by that restriction. Example: If a patient asks that mail be sent to an address other than where the patient lives, we are likely to agree. See Authorization to Disclose Patient Information form |
| Right to Access - Patients have a right to access their medical records. The right is qualified, not absolute. See Patient Access to Open Records |
| Right to Request Amendment - Like the right to access, the decision of whether to change the record is up to the treatment team. See Medical Record Amendment Request |
| Right to Account for Disclosures - Patients have the right to be told about all non-treatment disclosures unless they signed a specific authorization form allowing for the disclosure. See Accounting for Disclosing Patient Information |
Authorization to Disclose Patient Information form
HIPAA : Privacy
The Joint Commission : Management of 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..
