722.8.01.10 Confidential Patient Information - Regional West ...

REGIONAL WEST MEDICAL CENTER
SCHOOL OF RADIOLOGIC TECHNOLOGY
POLICY 722.8.01.10
04/20/79
CONFIDENTIAL PATIENT INFORMATION
Confidential patient information may not be given to unauthorized individuals.
Responsibility: Students, Program Director
Standard: Information Management
To protect the patient’s privacy, divulgence of any aspect of a patient’s care (financial,
medical, or personal data) except as required in the performance of clinical
responsibilities or for education purposes in a classroom situation, will result in
Corrective Action. Inquiries concerning patients or their families may be directed to the
supervisor, president of the facility, or the attending physician.
For the purposes of complying with Public Law 104-191, Section 160.102, Regional
West Medical Center shall be designated a “covered entity” as a health care provider
which transmits health information in multi-media formats, including electronic
information.
Section 164.501 defines Protected Health Information as any information whether oral
or recorded in any form or medium, created or received by a health care provider.
Individuals with access to patient information will be required to sign a Confidentiality
Statement and must comply with the general rules of uses and disclosures of Protected
Health Information, Section 164.502 of Public Law 104-191.
Divulgence of any aspect of a patient’s Protected Health Information except as required
in the performance of hospital duties for treatment, payment, and health care operations
will result in Corrective Action.
Job shadowers are identified as a component of the “Provisional Workforce” and will
therefore meet the following education requirements to protect the privacy of our
patients, students, and staff members:
1. The job shadower will be required to sign a Confidentiality Agreement. Students
16 -18 years of age must also have a parent’s signature on the Confidentiality
Agreement.
2. Each revisit will require the completion of a new Confidentiality Agreement.
Because of possible contact with patients and patient information, the Program will not
provide group tours of the Imaging Service Department. As an alternative the Program
will provide a presentation about the equipment and procedures completed in the
Department to these groups.
722.8.01.10 CONFIDENTIAL PATIENT INFORMATION 1

REGIONAL WEST MEDICAL CENTER
SCHOOL OF RADIOLOGIC TECHNOLOGY
POLICY 722.8.01.10
04/20/79
Tours of patient care areas involving protected health information may be presented in a
video/slide show format and may be scheduled through the Marketing and Public
Relations Department. Tours of actual patient care areas must limit exposure to
protected health information and be arranged through the Marketing and Public
Relations Department.
The Notice of Privacy Practices includes, but is not limited to:
A. Regional West Medical Center responsibilities:
1. Maintain the privacy of the Protected Health Information
2. Change the terms and scope of the Notice of Privacy Practices
3. Notify patients about revisions whenever there is a material change to the
uses or disclosures, the individual’s rights, Regional West Medical Center’s
legal duties, or other privacy practices stated in the notice.
B. A description of how the medical information will be used and disclosed.
1. Who will use this information, including clergy, family
2. Minimum disclosure
3. Understanding the medical record information
C. Patient rights related to the medical information
1. Right to see and obtain paper copies of the medical information
2. Right to correct or update the medical information
3. Right to obtain a list of disclosures that have been made
4. Right to request limits on uses and disclosures
5. Right to choose how we send information to the patient (alternative
communication)
6. Right to grant / withdraw authorization to use / disclose medical information.
7. Right to file a complaint to Regional West Medical Center and to the United
States Secretary of Health and Human Services without penalty or retaliation,
and information on how to obtain further information about filing complaints.
Except in an emergency treatment situation, Regional West Medical Center will make a
good faith effort to obtain a written acknowledgement of receipt of the notice provided,
and if not obtained, document a good faith effort to obtain such acknowledgement and
the reason why the acknowledgement was not obtained. The acknowledgement will be
kept in the electronic medical record.
Regional West Medical Center will keep records and compliance reports and will
provide them to the Secretary of Health and Human Services upon request. Regional
West Medical Center will cooperate with complaint investigations and compliance
reviews and will permit access to information by the Secretary. Compliance reports will
be reported to the Compliance Committee as requested by the Corporate Compliance
Officer.
722.8.01.10 CONFIDENTIAL PATIENT INFORMATION 2

REGIONAL WEST MEDICAL CENTER
SCHOOL OF RADIOLOGIC TECHNOLOGY
POLICY 722.8.01.10
04/20/79
________________________________
Daniel Gilbert, MSEd, RT(R)(CV)(MR)(CT)(QM)
Program Director
_________________________
Sharon McKinney, MPA
Director, Imaging Services
__________________________
Stephen C. Johnson MD, PhD
Medical Advisor
_________________________________
Jan Taylor
Vice President, Ancillary Services
_______ ___________________________
Todd S. Sorensen, M.D.
President / CEO
Reference: Hospital Policy #500.4.101, 500.4.102
Reviewed: 5/16/95, 6/18/98, 12/6/00, 7/31/01, 3/26/03, 6/28/06, 9/25/08, 12/1/11, 4/26/12, 2/21/13
Revised: 6/04/04, 12/1/11, 4/26/12
722.8.01.10 CONFIDENTIAL PATIENT INFORMATION 3