Patient Information Policy
Use and Disclosure of Protected Health Information For Facility
Directory Purposes
SCOPE:
All Louisiana State University (LSU) System health care
facilities and providers including, but not limited to
hospitals, physician practices, clinics, schools, etc. on the
LSU Health Sciences Center New Orleans Academic Campus.
Nota Bene: All LSU System health care facilities and providers
including, but not limited to hospitals, physician clinics,
schools, etc. on the LSU Health Sciences Center New Orleans
Academic Campus, are referred to in this policy as LSUHSC-NO.
PURPOSE:
To provide guidance to the health care facilities and providers
affiliated with LSUHSC-NO on the requirements of the Health
Insurance Portability and Accountability Act, Standards for
Privacy of Individually Identifiable Health Information (HIPAA
Privacy Regulations), for using a patient’s Protected Health
Information in a facility’s directory.
POLICY:
All LSUHSC-NO health care facilities and providers must provide
patients with the opportunity to agree to or prohibit the use or
disclosure of their Protected Health Information in a facility’s
directory.
DEFINITIONS:
Protected Health Information (sometimes referred to as “PHI”) –
for purposes of this policy means individually identifiable
health information, that relates to the past, present or future
health care services provided to an individual. Examples of
Protected Health Information include medical and billing records
of the patient.
For the purposes of the definition of "Designated Record Set":
- The term "record" means any item,
collection, or grouping of
information that includes PHI and is
maintained, collected, used or
disseminated by or for LSUHSC-NO.
- The term "record" also includes
patient information originated by
another health care provider and
used by LSUHSC-NO to make decisions
about a patient.
- The "term" record includes
tracings, photographs, videotapes,
digital and other images that may be
recorded to document care of the
patient.
Designated Record Set – is a group of records maintained by or
for LSUHSC-NO that are:
- The medical records and billing records about individuals
maintained by or for LSUHSC- NO ; or
- Any records used, in whole or part, by or for the LSUHSC- NO to
make decisions about individuals.
- Any record that meets this
definition of Designated Record Set
which are held by a HIPAA Business
Associate of LSUHSC- NO are part of
LSUHSC- NO’s Designated Record Set.
PROCEDURE:
| 1.0 |
The patient or personal
representative must be given an
opportunity to object to being
listed in LSUHSC-NO directory at the
time of admission or service. |
| 1.1. |
LSUHSC-NO must take the
following steps before including any
of a patient’s PHI in LSUHSC-NO’s
directory:
| 1.1.1. |
Inform the patient of
LSUHSC-NO’s policies
regarding its directory, if
any; and |
| 1.1.2. |
Provide the patient with
an opportunity to not be
included in LSUHSC-NO’s
directory listing or to
restrict some or all of
their PHI that LSUHSC- NO
desires to include in the
directory. |
| 1.1.3. |
If a patient does not
orally or in writing object
to his or her PHI being
listed in LSUHSC-NO
directory, the facility may
include the following PHI in
its facility directory:
- The patient’s name;
- The patient’s
location in the
facility;
- The patient’s
condition described in
general terms that do
not communicate specific
medical information
about the individual
(e.g., “fair”, “good”,
“critical”, etc.);
- The patient’s
religious affiliation;
|
| 1.1.4. |
If a patient does not
orally or in writing object
to his or her PHI being
listed in the LSUHSC-NO
directory, the facility may
disclose for directory purposes
such information:
- To members of the
clergy and
- Except for religious
affiliation information,
to persons other than
members of the clergy
who ask for the patient
by name;
|
|
| 2.0 |
The information described above
may be disclosed to members of the
clergy whether or not the clergy
asks for the patient by name. In
addition, the patient’s religion may
be made available to members of the
clergy. |
|
3.0 |
The form included as Attachment A may be
used to document the patient’s
preference to permit or prohibit
inclusion of PHI in LSUHSC- NO
directory. A notation may be made in
LSUHSC-NO’s computer system or any other
means of documentation may be used in
lieu of using Attachment A. |
|
4.0 |
Emergency Situations: |
| |
|
4.1. |
Emergency
situations may arise in which
the patient is not able to be
given the opportunity to object
to being listed in LSUHSC-NO’s
directory.
|
4.1.1. |
If
the opportunity to
object to being listed
in LSUHSC- NO directory
cannot practically be
provided because of the
patient’s incapacity or
an emergency treatment
circumstance, LSUHSC- NO
may list the patient in
the facility’s directory
if the listing is:
-
Consistent
with a prior
expressed
preference
of the
patient, if
any, known
to
LSUHSC-NO;
and
-
In the
patient’s
best
interest as
determined
by LSUHSC-NO
in the
exercise of
professional
judgment.
|
|
4.1.2. |
When
it becomes practical to
do so, LSUHSC- NO must
inform the patient of
the PHI included in
LSUHSC-NO directory, to
whom such PHI may be
disclosed, and must at
that point provide the
patient with an
opportunity to object to
being listed in LSUHSC-NO
directory. |
|
|
REFERENCE:
45 C.F.R .§164.510
|
