PURPOSE
To ensure that the patient’s right to privacy is protected by following the policies and procedures regarding confidentiality and use and disclosure of protected health information (PHI), as necessary.
POLICY
Mission Hospice and Home Care and its personnel will maintain as confidential all patient-protected health information. Protected health information will be used and disclosed in accordance with the hospice organization’s policies and procedures. (See “Uses and Disclosures of PHI” Policy No. 5-017.)
PROCEDURE
1. During the orientation process, this Confidentiality Policy will be reviewed by hospice personnel.
2. All hospice personnel will be required to sign a Confidentiality Agreement at the time of hire.
3. Hospice personnel will have access to the minimum necessary protected health information of patients needed to carry out their duties.
4. Use and disclosure of protected health information will be carried out according to accepted policies and procedures. (See “Uses and Disclosures of PHI” Policy No 5-017.)
5. Patients will not be discussed by clinical or nonclinical personnel outside of the context of professional conversation regarding those patients’ conditions and care.
6. Comments and conversations relating to patients made by physicians, nurses, or other hospice personnel will be made in confidential settings. It will be standard, acceptable, and necessary practice to share information with other members of the care team. The decision to share information can be aided by considering the intent of the discussion.
7. An agreement and consent for services form will be signed by the patient upon admission.
8. Valid authorizations for use and disclosure of information will be obtained, as required. (See “Authorizations for Use or Disclosure of PHI” Policy No. 5-018.)
9. Copies of clinical records, or excerpts of same, cannot be removed from hospice except by subpoena, where statutory law requires it, or on written authorization of hospice. This confidential information will only be mailed in an envelope designated “confidential.”
10. Patients will be allowed access to their protected health information. (See “Patient Requests for Access to PHI” Policy No 5-022.)
11. The organization respects the safety and security of patients and their property.
12. All clinical records will be kept in a locked cabinet/room when not being utilized. The Clinical Supervisor/Nursing Supervisor or designee will be responsible for the key. No unauthorized individual will be allowed access to clinical records.
13. The following patient information will be secured after business hours:
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- Clinical records
- Field clinical records
- Patient intake information
- Minutes of patient care meetings
- Performance improvement data
- Clinical notes prior to filing in clinical record
- Signed physician (or other authorized licensed independent practitioner) orders
14. Information contained in performance improvement reports will not contain individual patient or personnel information.
15. Mission Hospice and Home Care will apply appropriate sanctions against any hospice personnel who fail to comply with its privacy policies and procedures.
