Protected Health Information (PHI)

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

• HIPAA Health 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.