UNIVERSITY HOSPITAL AND CLINICAL PROGRAMS
PROFESSIONAL NURSING ORGANIZATION
POLICY STANDARDS

ADDENDUM:         J.4
EFFECTIVE:     12/87
REVISION:        08/08 APPROVAL:      08/08

SUBJECT: PATIENT CONFIDENTIALITY

SOURCE: Policy Standards, Section J, Governing Rules for Department of Nursing
  1. Confidential Information shall only be used and disclosed in accordance with UAMS policy. Refer to UAMS Medical Center Confidentiality of Patient Information Policy PS.2.02 .
  2. Only an authorized hospital employee may release Patient Directory information.
  3. Patient Directory information, including the one word statement of condition, will be released only after ensuring that the patient has not opted out of any or all of the Patient Directory.  Refer to  UAMS Administrative Guide Release of Patient Directory Information Policy 3.1.20 for additional details. 
  4. The one-word statement of condition released to friends or family members shall consist of one of the following four conditions:

a. Undetermined : the patient is involved in a procedure and/or awaiting assessment

b. Good: vital signs (pulse, temperature, blood pressure and respiration) are stable and within normal limits. Patient is conscious and comfortable: indicators are excellent

c. Fair: vital signs are stable and within normal limits. Patient is conscious, but may be experiencing some discomfort : indicators are favorable

d. Serious – vital signs may be unstable. Patient is acutely ill: indicators are questionable.  There are major complications. Prognosis is guarded

e. Critical – vital signs are very unstable. Patient may not be unconscious: indicators are unfavorable.

  1. Unauthorized release of confidential patient information shall be grounds for immediate termination.
  2. Inpatients can choose to grant permission for UAMS to share his or her confidential health information with a family member or friend by completing the Family or Friends Involved in your Care form (Med Rec 2408 (03/07) to specify who may receive the information and a password. The form will be placed on the chart, and only persons knowing this password should be given information when requested by telephone.  Refer also to UAMS Administrative Guide Use and Disclosure of PHI and Medical Records Policy 3.1.28 Section 6 for additional information regarding disclosures to family and friends involved in the patient’s care.
  3. For further information, see UAMS Medical Center Media Relations and Release of Information Policy A.2.01 Guidelines for reporting Coroner or Medical Examiner cases are found in UAMS Medical Center Death Documentation, Reporting, Certification, and Autopsy Policy ML.3.05.
  4. All requests by a patient or other party to view or receive a copy of a medical record shall be coordinated as outlined in  UAMS Administrative Guide Use and Disclosure of PHI and Medical Records Policy 3.1.28 Section 4
  1. No patient may be photographed without a signed consent.   
  2. Those patients who request or require for safety purposes confidentiality as to their presence at UAMS Medical Center will be handled in the following manner:

a.       Hospital Admission will be contacted to register the patient as "NO INFO" in the HBOC Medipac Patient Registration System. The patient will not be displayed on the INFO screen utilized by the hostess stations. However, the patient will be displayed on the unit census and records can be accessed using the patient’s MR number or legal name. No change in the patients’ label is required using this process

b.      In extreme cases, an alias may be used in order to maintain patient safety. It is important to note that if a legal name is changed to an alias during hospitalization all previous testing including lab, radiology, medications, blood bank, T&C’s etc., will not reflect the name change. This will result in inconsistent records. All ancillary departments should be contacted by the nursing unit immediately and informed of the assigned alias name. Hospital Admissions will register the patient using an alias ONLY at the direction of the Director of Admissions, Hospital Administration, or the on duty ADON. It is recommended that an alias be used at the time of initial registration into the system when possible.

c.       Using the assigned alias or the MR number staff may access patient records in HBOC. Once a patient is registered as an alias authorized HBOC users only can access the patient’s legal name. New patient labels should be printed and used for the remainder of hospitalization.

d.      Upon discharge Hospital Admission MUST be contacted to reverse the alias to the patent’s legal name. This is important for future access to the patients’ records.

e.       In circumstances where the alias is instituted for patient safety, Public Safety will be notified of the patient's location and circumstances surrounding the decision to assign an alias.

 

It is the responsibility of the patient if they desire visitors to inform family and friends of the assigned alias and their location.

  1. Electronic Information

a.       All electronic information (patient, employee, administrative and financial) stored on computer resources at UAMS is confidential and legally protected from disclosure.

b.      All campus and department policies regarding confidentiality developed to safeguard paper records apply equally to all data stored in electronic form.

c.       In order to maintain and control confidentiality of hospital and patient information stored on computer resources at UAMS, the Department of Nursing will require all users to be assigned individual ID and Password access codes. In addition, authorization to utilize various functions within the system will be assigned according to the user’s "need to know".

d.      Violation of security policies and/or misuse of confidential information will be grounds for immediate disciplinary action, up to and including termination.  Violation could result in civil or criminal penalties, as well.