Procedures
Written consent of the resident or the resident’s legally qualified representative is required for the release of medical information to persons not authorized to receive the information.
1.1 When certain portions of the medical record are so confidential that extraordinary means are necessary to preserve their privacy, these portions may be stored separately, provided the complete record is readily available when required for current care or follow-up or use in performance improvement activities.
2.1 The medical record will state that a portion has been filed elsewhere in order to alert authorized personnel of its existence. No information concerning a resident is accessible to anyone who is not authorized by virtue of his / her work in the facility or through legal instrument, such as a court order to possess such information unless 1.1 above is complied with.
3.1 Written consent is not required for the use of the medical record for any of the following purposes:
3.1.1 Automated data processing of designated information;
3.1.2 Use in activities concerned with the monitoring and evaluation of the quality of care; and
3.1.3 Official licensing or accreditation surveys for facility compliance.
4.1 Entries in the medical record are made only by individuals involved in the care and treatment of the resident. All entries in the medical record are dated and authenticated. All employee signatures are kept with corresponding typed signatures for purposes of authentication.
5.1 Rubber stamp signatures are not authorized. Sections of the medical record that are the responsibility of the physician are authenticated by the physician. Each clinical event is documented as soon as possible after its occurrence. Medical records with specific deficiencies that can be completed by a health care provider are termed incomplete records. Records of discharged residents are completed within 15 days following discharge. If a discharged record is not completed within 15 days, following discharge, it is considered delinquent. A medical record is considered “complete” when the required contents, including the discharge summary, are assembled and authenticated and when all final diagnoses and any complications are recorded, without the use of symbols or abbreviations. The medical record indicates when a portion of the record has been filed elsewhere, in order to alert authorized personnel of its existence. The facility information systems policies and procedures include security and back-up information. The system uses password codes with assigned levels of access. Facility staff are educated on release of information confidentiality policies and procedures.
NOTE: The resident and / or guardian will be assured that the provision of services is not contingent upon his / her decision concerning the release of any information.
Whether the information concerning the resident is obtained during the course of one’s regular duties or accidentally overheard while performing one’s work, employees must refrain from discussing such information with unauthorized persons within or outside of the facility or office in order to insure the client’s right to privacy.
All information regarding the Spirit Mountain, its personnel, residents and operating procedures is strictly confidential.
Any violation of confidentiality is considered a violation of patient rights and cause for immediate termination.
Patient Rights
The Privacy Rule provides patients with new Federal privacy rights, including the right to request restrictions of uses and disclosures of PHI, and the right to access, amend, and receive an accounting of disclosures of PHI. See 45 CFR §§164.522, 164.524, 164.526,164.528.
- Right to request a restriction of uses and disclosures
The Privacy Rule requires that programs allow patients to request that the program restrict uses or disclosures of PHI for the purpose of treatment, payment or health care operations and for involvement in the patient’s care and notification under 45 CFR §164.510(b). The program is not required to agree to a requested restriction. If, however, a program agrees to a restriction, the program may not then violate the agreed-upon restriction, except for emergency treatment purposes, so long as the program requests that the emergency treatment provider not further use or disclose the PHI. A covered entity may terminate the agreement to a restriction, effective after the patient has been informed of the termination. See 45 CFR §164.522(a).
The Privacy Rule gives the individual the right to request that communication of PHI be done by alternative means or to alternative locations (confidential communications). See 45 CFR §164.522(b)(1)(i). This might include the right to request that mail and telephone calls be limited to home or office location. The Privacy Rule requires programs to accommodate reasonable requests.
- Right to access PHI
Neither Part 2 nor the Privacy Rule requires programs to obtain written consent from individuals before permitting them to see their own records. Likewise, neither rule prohibits a program from giving a patient access to his or her own records, including the opportunity to inspect and copy any records that the program maintains about the patient. 42 CFR §2.23. However, the Privacy Rule permits programs to require that such requests be in writing. See 45 CFR §164.524(b)(1). The Privacy Rule provides patients with a right of access to inspect and obtain a copy of their PHI. See 45 CFR §164.524(a)(1).