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START. to begin…. Click. Privacy Patient Right to Accounting of Disclosures. Introduction. Patients have a right to receive a written list of certain disclosures we have made of their PHI. This course will explain UNC Health Care’s requirements for accounting of these disclosures. .
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START to begin… Click PrivacyPatient Right to Accounting of Disclosures
Introduction Patients have a right to receive a written list of certain disclosures we have made of their PHI. This course will explain UNC Health Care’s requirements for accounting of these disclosures.
Patients’ Request for Accounting of Disclosures Patients may ask for a listing of certain disclosures we have made of their PHI for up to six (6) years prior to the request (not including disclosures made prior to April 14, 2003). Requests for a listing of accounting of disclosures should be referred to your Privacy Officer.
Disclosures NOT Included The following disclosures are NOT required to be accounted for and will not be included on the Accounting of Disclosures listing: • Treatment, Payment, Healthcare Operations (TPO) • Disclosures authorized by the patient or authorized representative • Disclosures to the patient or persons involved with their care
More Disclosures NOT Included Other disclosures which we are NOT required to account for: • National security or intelligence purposes • Correctional institutions or law enforcement officials having lawful custody of an inmate • Incidental disclosures • Limited Data Sets used for research purposes
Disclosures Included in Accounting of Disclosures An accounting IS required for disclosures of which the patient may not be aware. Some examples include: • Disclosures required by law • Disclosures to Public Health Authorities (child and elder abuse, recording births and deaths, and communicable diseases) • Disclosures for Health Oversight purposes (trauma registry and cancer registry) • Disclosures for research purposes w/out patient authorization
Accidental Disclosures • Accidental disclosures outside of UNC Health Care should be accounted for and reported to your Privacy Officer. • For a more detailed listing of disclosures that must be accounted for, please refer to the UNC Health Care Accounting of Disclosures of PHI policy.
Logging of Required Disclosures • Disclosures that we are required to account for (log) must be entered into the institutional electronic disclosure tracking system (Disclosure Trac).
Departmental Responsibilities for Accounting of Disclosures • Identify those disclosures which require an accounting. • Ensure internal procedures are in place to enter required disclosure information into the institutional electronic disclosure tracking system (Disclosure Trac). • See UNC Health Care HIPAA Web site (intranet.unchealthcare.org/hospitaldepartments/hipaa) for Disclosure Trac training documentation.
Example 1 Susan, a Patient Services Representative in the billing office, is faxing PHI using the appropriate coversheet to a UNC Community Based Clinic. She receives a call from a restaurant that the fax was received there, not at the intended destination. Is this a disclosure that Susan must log into the Institution’s Disclosure Trac Database?
Example 1 - Answer Yes. When mistakes result in a disclosure of PHI to an unauthorized person, you MUST account for that in the database. Susan must also report the accidental disclosure to her Privacy Officer.
Example 2 Amanda Jones, the mayor of a small local town, is admitted to UNC Hospitals for surgery. She gives permission for her name, location, and religious affiliation to be included in the hospital’s patient list. She agrees that the disclosure of that information may be made to members of the clergy and to people who ask for her by name. While in the hospital she is diagnosed with active tuberculosis (TB). Upon discharge, Mayor Jones asks the hospital for an accounting of her PHI disclosures.
Example 2 During Mayor Jones’ stay the following disclosures were made: • Her daughter calls and is told that her mother is “stable.” • Later the information desk gives Reverend Smith a list of the names of all newly admitted patients, including hers, and their religious affiliation. • The TB diagnosis was reported to the Public Health Department, as required by law. Which of these disclosures should have been tracked so we may give her an accurate accounting?
Example 2 - Answer The third disclosure to the Public Health Department. Mayor Jones authorized the first two disclosures when she agreed for her name to be included in the patient and clergy lists, upon signing the General Consent for Treatment form. The disclosure to the Public Health Department was required by law and did not require patient authorization. Therefore, the disclosure of PHI must be tracked and provided on the Accounting of Disclosures list to the patient.
Prev Next For more information: Intranet.unchealthcare.org/hospitaldepartments/hipaa
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