HospitalInspections.org

Based on a review of documentation and interview, it was determined that the facility failed to ensure the right of patients to the confidentiality of his or her clinical record.

Findings were:

? Patient Kardex forms were received at Department of State Health Services (DSHS)via fax for 5 out of 7 patient medical records reviewed (Patients #1, 2, 3, 5, and 6). The Kardex form included the following personal health information: the patient medical record number, birth date, admission date, primary diagnosis, medical history, hospitals/surgery history, allergies, and diet order.
? SBAR (Situation, Behavior, Assessment, and Re-Assessment)Fax Reports were received at DSHS via fax for 2 out of 7 patient medical records reviewed (Patients # 4 and 7. The SBAR Fax Report included the following personal health information: patient name, age, sex, weight, height, chief complaint, admitting doctor, admission diagnosis, vital signs, allergies, medical history, medications administered in the emergency room, physical assessment information and other information.
? Several pages of handwritten SBAR (Situation, Behavior, Assessment, and Re-Assessment) notes were received at DSHS on 6 out of 7 patient medical records reviewed (patients # 1, 2, 3, 4, 5, and 6). The handwritten SBAR notes contained personal health information including input and output measurements, labs, and orders.

Facility policy & procedure titled Health Information Management stated in part
"Paper Documents Containing PHI
A. Facilities must ensure that reasonable safeguards are in place to protect paper
documents containing PHI:
1. to the extent feasible:
i. PHI should be removed from high visibility areas, even if those areas are
not open to the public, and
ii. PHI should be maintained in a confidential manner in order to prevent
workforce members and others that do not have a need to know from
accessing such PHI.
iii. Documents must not be left unattended in areas accessible to the public
(e.g. , charts may not be left unattended on a counter that is open to the
public).
iv. Access to areas containing PHI must be limited to authorized
personnel.
2. Documents containing PHI must be disposed of securely (e.g., place PHI in
shred bins not regular trash cans or recycle bins that will not be shredded). The
facility must eliminate unnecessary regular trash cans. "

Facility Document titled Patient Rights stated in part, " Confidentiality of your health care information/medical records and communication, written or oral, between you and your healthcare providers except as otherwise provided for by law or contracts with your third party payer. "

The issues regarding the right to confidentiality of clinical records was confirmed in an interview with the Director of Quality Management on the afternoon of 7/16/12.