Confidentiality of Patient Medical Record

POLICY:

Patient confidentiality will be maintained regarding every
aspect of care in this facility and patient information and
to comply in every manner with State and Federal law
pertaining to the release of information from the patient
medical record.  Any employee who unlawfully discloses
patient information will be subject to disciplinary
action--up to and including termination of employment.

Confidential patient information includes, but is not limited
to patient clinical information, clinical protocols and
patient lists.

There are three types of allowed records releases:

1.  Requests TO this organization to forward medical records
    out of the office to other providers or to an insurance
    company or attorney.

2.  Requests FROM this organization to receive medical
    records from another provider of care. 

3.  Requests for this organization to forward medical records
    out of the office to miscellaneous entities. 

Requests for release of sensitive information relating to
psychiatric treatment, alcohol/substance abuse treatment, and
records documenting the patient's HIV status must separately
specify authorization for release of medical information.

Requests for release of medical records will be fulfilled
within five days of receipt.  Requests unable to be fulfilled
(i.e., chart missing, request not properly executed, etc.)
will be returned to the requestor as soon as possible.

PROCEDURE:

1.  All requests to release copies of patient charts must be
    in writing and contain the following information:

    A.  Designation of the name of person, company or agency
        to whom the information is being released.
    B.  Specification of the period of time to be covered.
    C.  Signature of the patient or his/her legally
        qualified representative.

The following protocol will be followed:

    A.  The subject chart is pulled or
        if EMR accessed electronically
        and given to the appropriate Staff member with the 
        request attached to the front of the chart.
    B.  The Staff member reviews the chart and designates
        the content to be released.
    C.  Designated personnel photocopy or
        if EMR print
        indicated pages.
    D.  Date of release is documented onto the original
        release form which is then photocopied.   The
        original is inserted or scanned into the patient
        chart and becomes a permanent part of that patient's
        medical record; the photocopy is attached to the
        front of the photocopied packet for return to the
        requestor.
    E.  The photocopied packet is forwarded to the requestor.
In special circumstances, a patient may hand-carry a records
release request to the office and wait while records are
copied for hand-carrying to another provider/requestor. 
Logistical limitations make this a necessarily rare
occurrence.

2.  Requests for release of medical records may be generated
    by this organization, e.g., in order to obtain records of
    patients new to the practice or to obtain records of
    patients who have received care external to the practice.

    The following procedure is followed when a request for
    release of patient information to another party (health
    care provider, attorney, etc.) is generated by this
    organization:

    A.  The release request is signed by the patient
    B.  The date that the request is generated is noted on
        the front of the release form.
    C.  The release is photocopied with the original
        forwarded to the party in possession of the records
        and the photocopy maintained in a 'tickler' binder. 
    D.  Upon receipt of the requested records, the 'tickler'
        copy is removed from the binder and discarded. 
    E.  On a moving 30-day basis, tickler copies are checked
        and re-sent as necessary to stimulate a response.

3.  Patients desiring to exercise their right of correction
    or amendment of the personal health information  
    contained  within the medical record, may petition for
    such correction using the appropriate forms.  The
    process for such petition is noted on the form.
4.  Occasionally, a patient may request that medical records
    be forwarded out of the office to miscellaneous
    entities; or, other entities with a legitimate concern 
    may make a request; examples are noted below:

    A.  Non-staff persons who make inquiries concerning
        patients must present proper authorization from the
        patient.  The Medical Director will extend all
        reasonable courtesy, keeping the interests of all
        parties in perspective.
    B.  All requests for information by any agent of the
        press or media shall be referred to the Medical
        Director or designee.
    C.  Requests by patients for information about their own
        records shall be referred to the attending Staff
        member in charge of their care.  Patients wishing
        copies of their personal medical record must sign
        the release or forward a signed release.
    D.  Police inquiries shall be referred to the Medical
        Director or designee.
    E.  Requests for information regarding a deceased
        patient shall be referred to the attending
        physician.
        Under no circumstances shall the fact a patient is
        deceased be released by any staff member.  Requests
        for any information about a coroner's case shall be
        referred to the Office of the Chief Medical Examiner.
    F.  The Medical Director, with the written approvals
        of the Governing Body and the Medical Executive
        Committee, will permit use of patient
        medical records for research purposes only under
    stringent regulations, including IRB review, as 
        appropriate. 

Should it be discovered that there has been a breach to any
individual's private health care information, all
requirements regarding the breach and individual notification
will be followed. 

5.  Charts are intermittently evaluated for possible removal
    to storage; the following circumstances may trigger such
    action:

    A.  Charts of deceased patients.
    B.  Patients who have moved from the area and
        transferred copies of their records to a new
        provider.
    C.  Patients who have transferred to another staff
        member for on-going care.
 

See the 'RELEASE OF MEDICAL RECORD' forms and the relevant
HIPAA forms.

 

Approved By Governing Board
PR.1
Control #14.4
GUPTA GASTRO