Module 1 General Privacy

1. START to begin… Click Module 1 General Privacy

2. Prev Next Introduction • UNC Health Care System (UNC HCS) has always treated Privacy and Confidentiality as a priority. • In this course, you will learn about UNC HCS’s privacy policies and procedures. • You are required to complete privacy training every year. • You may be required to complete additional online training modules every year, depending on your job responsibilities. • All UNC HCS workforce members must comply with our privacy policies and procedures.

3. Course Objectives After completing this course, you should understand: • That privacy is your responsibility! • How you can recognize situations where sensitive information may be handled improperly. • How you can protect patient and confidential information in common workplace situations. • That you will be held responsible for improperly handling sensitive information.

4. To meet the objectives of this course, we will visit several areas of a fictional but typical healthcare system.

5. Disclaimer The people and events in this story are based on real events. The names and locations have been changed, not to protect the innocent or the guilty, but to comply with HCS privacy and security policies.

6. “A Day in the Clinic”

7. This morning, at a healthcare facility very much like yours . . .

8. Sharing Information With Persons Not Involved in Care Janice, a hospital clinic employee, was in a car accident and brought by ambulance to the ER. Her physicians discovered that she is pregnant. Janice’s clinic co-worker, Tamika, found out Janice was in the ER and called to ask about her condition. Tamika was told Janice suffered minor bruises and cuts, but was stable. Did the ER follow proper procedures in releasing information to Tamika?

9. Sharing Information With Persons Not Involved in Care No! The ER should have first checked to see if Janice had requested additional privacy (“opt-out”) and if not, only have answered “Janice is in fair condition”.

10. Accessing Information Tamika went to the ER, picked up Janice’s chart and read it. Tamika then went to see Janice and said, “I’m so glad that you and the baby are both OK!” Should Tamika have read Janice’s chart?

11. Accessing Information No! Since Tamika was not directly involved in Janice’s care, she should not have looked at her friend’s chart, even though Tamika is a hospital employee.

12. Sharing Information with Family and Friends Joe McCleod, who is a recent college graduate, has been admitted to the ER for treatment. He “opted out” of communications with family and friends and specifically indicated that nothing about his condition or treatment was to be discussed with his parents.

13. Sharing Information with Family and Friends Unable to learn what is happening with their son, Mr. & Mrs. McCleod ask their friend, Dr. Steve, who isn’t involved in Joe’s care, to review Joe’s records. Dr. Steve reviews the records and informs Joe’s parents that Joe has hepatitis B and shows signs of drug abuse. Were proper procedures followed when sharing information with Joe’s parents?

14. Sharing Information with Family and Friends No! Joe’s parents should not have received information about Joe’s condition because he had “opted out” of sharing information with family and friends. In addition, Dr. Steve should not have reviewed Joe’s records unless he was directly involved in Joe’s medical care.

15. Inappropriate Disclosure Passing through a crowded check-in area, Nurse Betty overhears Jamal (the clinic check-in clerk) telling a patient on the phone that he needs a follow-up appointment because his HIV test just came back positive. She notices waiting patients listening intently to the conversation. Is Jamal taking the proper precautions?

16. Inappropriate Disclosure No! Jamal should have done at least one of the following: • Spoken in a lower voice in order not to be overheard by the other patients. • Waited until the clinic check-in area was less crowded. • Moved to another, moreprivate area prior to making the call.

17. Inappropriate Use and Disposal On her way to morning rounds, Nurse Betty is approached by Dr. Steve, who hurriedly sticks a note in her hand before going to another exam room. Betty is a bit surprised to see that an invitation for drink and dinner is written on the back of a patient’s lab report. “Really!?” Betty thinks to herself before throwing the crumpled note into the nearest trash bin. What’s wrong with this scenario?

18. Inappropriate Use and Disposal Dr. Steve should have: • Disposed of the lab results appropriately • NOT used a document containing personal patient information for his own personal notes • NOT given patient information to a co-worker who wasn’t involved in the patient’s care. Nurse Betty should have: • Disposed of the paper appropriately (for instance, in a shredder or confidential disposal bin).

19. Inappropriate Disclosure in a Public Area Wanda (an Accounts Payable clerk) steps onto an elevator and is surprised to overhear a nurse and a doctor discussing the potential transfer of a psychiatric patient named Joe McCleod. What should Wanda do?

20. Inappropriate Disclosure in a Public Area Wanda should remind the doctor and nurse that this information is confidential and should not be discussed in a public area.

21. Lost PHI and Inappropriate Access Bill, an environmental services employee working in a hallway after hours, finds a piece of paper lying on the floor. Upon examination, he discovers that it is a lab report containing the name of his favorite NASCAR driver, so he calls his co-worker, Tom, over to take a look at it. . . . What’s wrong with this scenario?

22. Lost PHI and Inappropriate Access • The lab report was left in a non-secure area • Bill should NOT have read the report • He should NOT have shared the information with Tom • He SHOULD have notified: • His supervisor OR • The Privacy Officer

23. Incidental Disclosure During rounds, Dr. Steve pulled the curtain around Mrs. Curmudgeon’s bed and quietly discussed her diagnosis and prognosis with her, after checking that her roommate was not present. However, her roommate returned to her bed just in time to overhear the discussion. When Mrs. Curmudgeon discovered that her roommate had overheard the discussion, she became very upset. Did Dr. Steve handle the situation correctly?

24. Incidental Disclosure Yes! By pulling the curtain and speaking in a low voice, Dr. Steve took the proper steps. The roommate’s overhearing was an “incidental” disclosure. These cannot always be prevented, even with the appropriate safeguards.

25. Summary • You should consider ALL patient information as confidential. • It should ONLY be accessed by, and shared with, authorized persons. • It is YOUR responsibility to protect patient information – and to report any breaches of confidentiality.

26. Resources For more information: • UNC Health Care Web Site (http://www.unch.unc.edu/hipaa) • UNC HCS Privacy Policies & Guides • UNC HCS Privacy Reference Sheet • Links to other resources • Your Privacy Officer

27. Congratulations! Prev You have now successfully completed the online HIPAA General Privacy Module - Click <HERE> to end show -