722.8.01.10 Confidential Patient Information - Regional West ...
722.8.01.10 Confidential Patient Information - Regional West ...
722.8.01.10 Confidential Patient Information - Regional West ...
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REGIONAL WEST MEDICAL CENTER<br />
SCHOOL OF RADIOLOGIC TECHNOLOGY<br />
POLICY <strong>722.8.01.10</strong><br />
04/20/79<br />
CONFIDENTIAL PATIENT INFORMATION<br />
<strong>Confidential</strong> patient information may not be given to unauthorized individuals.<br />
Responsibility: Students, Program Director<br />
Standard: <strong>Information</strong> Management<br />
To protect the patient’s privacy, divulgence of any aspect of a patient’s care (financial,<br />
medical, or personal data) except as required in the performance of clinical<br />
responsibilities or for education purposes in a classroom situation, will result in<br />
Corrective Action. Inquiries concerning patients or their families may be directed to the<br />
supervisor, president of the facility, or the attending physician.<br />
For the purposes of complying with Public Law 104-191, Section 160.102, <strong>Regional</strong><br />
<strong>West</strong> Medical Center shall be designated a “covered entity” as a health care provider<br />
which transmits health information in multi-media formats, including electronic<br />
information.<br />
Section 164.501 defines Protected Health <strong>Information</strong> as any information whether oral<br />
or recorded in any form or medium, created or received by a health care provider.<br />
Individuals with access to patient information will be required to sign a <strong>Confidential</strong>ity<br />
Statement and must comply with the general rules of uses and disclosures of Protected<br />
Health <strong>Information</strong>, Section 164.502 of Public Law 104-191.<br />
Divulgence of any aspect of a patient’s Protected Health <strong>Information</strong> except as required<br />
in the performance of hospital duties for treatment, payment, and health care operations<br />
will result in Corrective Action.<br />
Job shadowers are identified as a component of the “Provisional Workforce” and will<br />
therefore meet the following education requirements to protect the privacy of our<br />
patients, students, and staff members:<br />
1. The job shadower will be required to sign a <strong>Confidential</strong>ity Agreement. Students<br />
16 -18 years of age must also have a parent’s signature on the <strong>Confidential</strong>ity<br />
Agreement.<br />
2. Each revisit will require the completion of a new <strong>Confidential</strong>ity Agreement.<br />
Because of possible contact with patients and patient information, the Program will not<br />
provide group tours of the Imaging Service Department. As an alternative the Program<br />
will provide a presentation about the equipment and procedures completed in the<br />
Department to these groups.<br />
<strong>722.8.01.10</strong> CONFIDENTIAL PATIENT INFORMATION 1
REGIONAL WEST MEDICAL CENTER<br />
SCHOOL OF RADIOLOGIC TECHNOLOGY<br />
POLICY <strong>722.8.01.10</strong><br />
04/20/79<br />
Tours of patient care areas involving protected health information may be presented in a<br />
video/slide show format and may be scheduled through the Marketing and Public<br />
Relations Department. Tours of actual patient care areas must limit exposure to<br />
protected health information and be arranged through the Marketing and Public<br />
Relations Department.<br />
The Notice of Privacy Practices includes, but is not limited to:<br />
A. <strong>Regional</strong> <strong>West</strong> Medical Center responsibilities:<br />
1. Maintain the privacy of the Protected Health <strong>Information</strong><br />
2. Change the terms and scope of the Notice of Privacy Practices<br />
3. Notify patients about revisions whenever there is a material change to the<br />
uses or disclosures, the individual’s rights, <strong>Regional</strong> <strong>West</strong> Medical Center’s<br />
legal duties, or other privacy practices stated in the notice.<br />
B. A description of how the medical information will be used and disclosed.<br />
1. Who will use this information, including clergy, family<br />
2. Minimum disclosure<br />
3. Understanding the medical record information<br />
C. <strong>Patient</strong> rights related to the medical information<br />
1. Right to see and obtain paper copies of the medical information<br />
2. Right to correct or update the medical information<br />
3. Right to obtain a list of disclosures that have been made<br />
4. Right to request limits on uses and disclosures<br />
5. Right to choose how we send information to the patient (alternative<br />
communication)<br />
6. Right to grant / withdraw authorization to use / disclose medical information.<br />
7. Right to file a complaint to <strong>Regional</strong> <strong>West</strong> Medical Center and to the United<br />
States Secretary of Health and Human Services without penalty or retaliation,<br />
and information on how to obtain further information about filing complaints.<br />
Except in an emergency treatment situation, <strong>Regional</strong> <strong>West</strong> Medical Center will make a<br />
good faith effort to obtain a written acknowledgement of receipt of the notice provided,<br />
and if not obtained, document a good faith effort to obtain such acknowledgement and<br />
the reason why the acknowledgement was not obtained. The acknowledgement will be<br />
kept in the electronic medical record.<br />
<strong>Regional</strong> <strong>West</strong> Medical Center will keep records and compliance reports and will<br />
provide them to the Secretary of Health and Human Services upon request. <strong>Regional</strong><br />
<strong>West</strong> Medical Center will cooperate with complaint investigations and compliance<br />
reviews and will permit access to information by the Secretary. Compliance reports will<br />
be reported to the Compliance Committee as requested by the Corporate Compliance<br />
Officer.<br />
<strong>722.8.01.10</strong> CONFIDENTIAL PATIENT INFORMATION 2
REGIONAL WEST MEDICAL CENTER<br />
SCHOOL OF RADIOLOGIC TECHNOLOGY<br />
POLICY <strong>722.8.01.10</strong><br />
04/20/79<br />
________________________________<br />
Daniel Gilbert, MSEd, RT(R)(CV)(MR)(CT)(QM)<br />
Program Director<br />
_________________________<br />
Sharon McKinney, MPA<br />
Director, Imaging Services<br />
__________________________<br />
Stephen C. Johnson MD, PhD<br />
Medical Advisor<br />
_________________________________<br />
Jan Taylor<br />
Vice President, Ancillary Services<br />
_______ ___________________________<br />
Todd S. Sorensen, M.D.<br />
President / CEO<br />
Reference: Hospital Policy #500.4.101, 500.4.102<br />
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<br />
Revised: 6/04/04, 12/1/11, 4/26/12<br />
<strong>722.8.01.10</strong> CONFIDENTIAL PATIENT INFORMATION 3