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Protected Health Information (PHI). Privileged Communication. An exchange of information between two individuals in a confidential relationship. (Examples: Lawyer-client, Doctor-patient)
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Privileged Communication • An exchange of information between two individuals in a confidential relationship. (Examples: Lawyer-client, Doctor-patient) • A privileged communication is a private statement that must be kept in confidence by the recipient for the benefit of the communicator.
Medical Records • Contain Protected Health Information • Fall under regulations of HIPAA • Deliberate alteration of a medical record is illegal and unethical. • Errors can be corrected by a health professional, if it is done correctly • Patients may request copies of medical records and request corrections to entries.
HIPAA • HIPAAHealth Insurance Portability and Accountability Act • Federal protection for privacy of health information in all states. • Requires healthcare workers, insurance companies, and other professionals, to keep Protected Health Information (PHI) confidential.
Examples of Protected Health Information - PHI • Name • Birth Date • Fax Number • Account Number • Street Address • Admission Date • email address • License Plate Number • City • Discharge Date • Social Security Number • Date of Death • Medical Record Number • Full Face Photographic Images • Zip Code • Telephone Number • Finger prints • Any Other Unique Identifying Number, Characteristic, or Code
The Privacy Rule • Provides patients with certain rights - these rights are commonly referred to as the PATIENT PRIVACY RIGHTS. • These rights are communicated to the patient in the Notice of Privacy Practices. • If a patient wishes to exercise any of these Patient Privacy Rights (which are outlined on the next slide), they must do so in writing. • Example – A patient has a right to obtain a copy of all medical records – A fee may be charged and it may need to be requested days in advance.
The Patient Privacy Rights • Right to access PHI • Right to request an amendment to PHI • Right to request restrictions on how PHI is used for treatment, payment, and healthcare operations • Right to receive confidential communications • Right to request an accounting of disclosures • Right to complain to the Department of Health and Human Services’ Office for Civil Rights
Examples of Privacy Compliance Rules • Keep all PHI locked and secured when you are away from your work area. • Do not include any patient identifiers in the subject line of an email. • Do not discuss PHI in public or common areas. • Computer passwords should be complex
Fixing Errors in Medical Records • Paper records – Draw one line through the error (it should remain readable). Date and initial the correction. • Electronic records - make a new entry with today's date and time, stating your name and that you are correcting an error in a previous entry; give the date and time of the previous entry; and enter the corrected data or explanation.