Date
of Last Review 5/6/08
SME: Director of Health Information Management
Information that identifies an individual and relates to an individual as follows
is considered Protected Health Information (PHI):
 | Past, present, or future physical, mental health, or condition |
| The provision of health care |
| The past, present, or future payment for the provision of health care |
Almost all elements of the medical record are PHI, as well as certain payment and demographic information
Federal regulations require that patients be given, upon request, an accounting of certain disclosures of their protected health information.
Disclosures that require recording are accounted for on a Disclosure Log or Chart FactsTM as applicable, see Handling disclosures.
There are four types of disclosures of protected health information (PHI) as follows:
Types |
Descriptions | ||||||||||||||||||||||||
1 |
Disclosures made in the course of doing hospital business for:
This type of disclosure does not require recording. | ||||||||||||||||||||||||
2 |
Disclosures for reasons OTHER than in Type 1, that are made under a patient's specific signed authorization. (Refer to your department's Release of Information Guide for a list of disclosures that require a written authorization.) Examples include disclosures to:
This type of disclosure does not require recording. | ||||||||||||||||||||||||
3 |
Disclosures of de-identified patient information, see De-identified PHI. This type of disclosure does not require recording. | ||||||||||||||||||||||||
4 |
Disclosures for reasons OTHER than in Type 1, and for which the patient HAS NOT given a specific, written authorization. Examples include disclosures to:
Disclosures of this type must be recorded on the disclosure log or Chart FactsTM as applicable. |
PHI is "de-identified" when it cannot be traced back to a patient or a patient's family member. A document or electronic record is considered to be de-identified if the following elements are removed:
Categories |
Description | ||||||||||||||||
Dates |
| ||||||||||||||||
Names |
| ||||||||||||||||
Addresses |
| ||||||||||||||||
Identifying numbers |
| ||||||||||||||||
Biometric identifiers |
|
The following table lists examples of possible disclosures and how they would be handled by staff:
Disclosure is to... |
Accounting/ |
Document as follows... | ||||||
Lab Corp |
Is NOT required |
N/A | ||||||
Pharmacy (McKesson) |
Is NOT required |
N/A | ||||||
IM and other consultants |
Is NOT required |
N/A | ||||||
|
Is NOT required |
N/A | ||||||
MHMRA's:
|
Is NOT required |
N/A | ||||||
Other aftercare providers |
Is NOT required |
N/A | ||||||
The patient's primary care provider |
(If the disclosure is necessary for treatment purposes) Is NOT required |
N/A | ||||||
|
(If the disclosure is necessary for treatment purposes) Is NOT required |
N/A | ||||||
A care manager |
(If the disclosure is necessary for treatment purposes) Is NOT required |
N/A | ||||||
A clinical researcher for a current or future protocol |
IS required |
Note the disclosure in the disclosure log | ||||||
MHMRA's Court Liaison for:
|
IS required |
Note the disclosure in the disclosure log | ||||||
A probate court guardianship investigator |
IS required |
HIM documents the disclosure in Chart FactsTM | ||||||
Satisfy a judicial subpoena for any criminal or civil case |
IS required |
HIM documents the disclosure in Chart FactsTM | ||||||
Satisfy an attorney subpoena for any criminal or civil case |
IS required |
HIM documents the disclosure in Chart FactsTM | ||||||
Harris County Juvenile Probation staff for providing health care, to ensure patient and staff safety, or to maintain good order on the unit |
Is NOT required |
N/A | ||||||
The Texas Department of Health as part of an investigation |
IS required (unless the patient has signed an authorization) |
If there is no authorization, note the disclosure in the disclosure log | ||||||
The JCAHO as part of a survey or investigation |
IS required (unless the patient has signed an authorization) |
HIM documents the disclosure in the Chart FactsTM | ||||||
A state licensing authority for physicians, nurses, licensed social workers, licensed professional counselors, etc., for investigating a complaint |
IS required (unless the patient has signed an authorization) |
If there is no authorization, note the disclosure in the disclosure log |
The Joint Commission : Management of Information
HIPAA : Privacy
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