CPCT Study Guide: Privacy, Confidentiality, and Reporting Work Injuries

Privacy and Confidentiality

• Health Insurance Portability and Accountability Act (HIPAA) of 1996:

  • Federal law directing healthcare workers in handling Protected Health Information (PHI).
  • Guards against misuse or inappropriate disclosure of PHI.
  • Establishes the foundation for privacy protection of health information and sets the standards for the transmission of electronic health information to ensure confidentiality.

• Protected Health Information (PHI):

  • Includes all information related to patient care in medical and electronic health records.
  • Details what information is confidential and authorized release of this information.

• HIPAA Rules Protect:

  • Demographic data.
  • Information relating to treatment, medications, and diagnostic testing.

• Exceptions to Protection:

  • Information without any way to identify the patient does not require the same protection.
  • Researchers and those who gather public health statistics may use it.

• Disclosure Restrictions:

  • You may not disclose any information about a patient to anyone who has no involvement in that patient’s care unless the patient has given written authorization.
  • A friend or family member being present does not automatically permit PHI disclosure.
  • Determine who has access by asking patients and ensuring a consent form is on file.

• Guidance:

  • Any time you are unsure about sharing patient information, seek guidance from a nurse or manager before risking an illegal disclosure.
  • Never assume it is okay to disclose information to anyone who asks for it.

• Permissible Sharing of PHI:

  • You may share PHI with patients’ providers, medical specialists, nurses, and billing, accounting, and healthcare insurance employees.
  • Example: Releasing test results from an emergency department visit to the provider for follow-up care.

• Consent Requirements:

  • HIPAA originally required written consent for disclosure of all patient information.
  • Revision requires providers to notify patients of their privacy policy and make a reasonable effort to obtain written acknowledgment of this notification.

• Discussions:

  • Avoid discussing patient information with colleagues in public places or with those who have no direct involvement in that patient’s care or treatment.
  • Avoid discussing patients by their diagnosis, name, bed number, or other PHI in places where others can overhear the information, such as hallways, elevators, and break rooms.

• Phone Communication:

  • When discussing patients’ information over the phone, identify the person calling and their need for the information, check with the patient about authorization, or refer the caller to the patient.
  • Speak at a low volume to prevent anyone from overhearing confidential information.

• Electronic Health Record:

  • A system-wide computer application for the storage, manipulation, and retrieval of patient information.

• Patient Rights:

  • Patients have the right to look at and receive copies of their own records.
  • Only employees with access to the system can get this information.
  • If a breach occurs, these actions are traceable.

• Penalties for Illegal Access:

  • Anyone who accessed these records illegally can be reprimanded, counseled, fired, fined, or otherwise penalized according to HIPAA regulations.

• Patient Requests:

  • When patients request their records, follow facility protocols for referring them to the right person or department.

• Computer and Tablet Use:

  • Use your own secure password and log off completely before leaving it unattended.
  • Never share your password with anyone, and never allow anyone else to use the computer after you have logged into it.
  • Do not write down your password and leave it where others might see it.
  • If you forget your password or it has expired, follow facility procedures for acquiring a new one.

• Printed Information:

  • If you print copies of patient information or a log to assist you with completing assignments, shred these after use.

• Screen Visibility:

  • When at a computer terminal, position the screen so that people passing by cannot view it.

• Social Media:

  • Never connect with patients on social media or engage in any posting or commenting about patients or about workplace issues.

• Repercussions:

  • Repercussions for breaches of patient confidentiality can be steep fines or the potential loss of employment.

Reporting Work Injuries

• Accident Reporting:

  • Even with careful adherence to safety guidelines, accidents and injuries can occur.
  • Report accidents immediately to the charge nurse for assessment of the injured individual, and fill out any necessary forms.
  • Do not assign blame or offer opinions. Just report the facts as you have observed them.
  • Follow facility procedures carefully.

• Incident Reports:

  • In most cases, an incident or occurrence report is necessary.
  • If a patient is injured, generally a nurse will fill out the report.
  • This form provides a record of the event for the facility and assists risk managers and quality assurance staff in investigating the incident and devising strategies to prevent future occurrences.
  • They observe for trends to address, create, and implement a plan for prevention.
  • Incident reports are also necessary for other types of occurrences outside the routine operation of a facility, such as a medication error.

• Employee Injuries and Workers’ Compensation:

  • When an employee is injured, correctly completed forms are necessary for workers’ compensation coverage.
  • If the injury is serious enough, the facility will have a protocol for visiting a provider, urgent care center, or emergency department.
  • If you are injured, make sure to contact the facility’s human resources department.
  • The human resources professionals might direct you to specific providers or facilities to diagnose and treat the injury under their workers’ compensation provisions.

• Reporting Even Minor Injuries:

  • Even if you think an injury is insignificant, report it and fill out the forms, because it could cause complications or problems later on.