Patient Charts

"Safeguarding" or protecting patient charts is an important way to help ensure the confidentiality and security of patient health information. There are many ways in which you can take steps to safeguard information contained in patient charts. For example, the Privacy Rule does not prohibit the following practice, however, reasonable precautions as indicated below must be taken to protect an individual's privacy:

Patient Charts (Paper or Electronic)

Practice Examples

Maintaining patient paper charts at bedside or outside of exam rooms, displaying patient names on the outside of patient charts, or displaying patient care signs (e.g., "high fall risk" or "diabetic diet") at patient bedside or at the doors of hospital rooms. Having patient charts in electronic format accessible via computers located in patient rooms or in nursing units.

Possible Safeguards

Possible safeguards for paper charts may include: reasonably limiting access to these areas, ensuring that the area is supervised, escorting non-employees in the area, or placing patient charts in their holders with identifying information facing the wall or otherwise covered, rather than having health information about the patient visible to anyone who walks by. Do not leave charts or papers on counters unattended in an area that is accessible to the public.

Possible safeguards for electronic charts may include: installation of computer screen privacy filter, minimize/lock your workstations to prevent unauthorized viewing or access of patient electronic medical records.

Whiteboards

Practice Example

Use of X-ray lightboards or in-patient logs, such as whiteboards, at a nursing station.

Possible Safeguards

Possible safeguards may include:

• placing the X-ray lightboard in an area generally not accessible by the public, or
• ensuring that the nursing station whiteboard is not readily visible to the public, or
• implementing any other safeguard (limit the use if patient identifiers e.g., utilize patient last, first initial and abbreviate other information to reasonably limits incidental disclosures to the general public.)
• Minimize/lock your workstation to prevent others from viewing electronic whiteboards.

Communications Safeguards

• Be aware of your surroundings and lower your voice when discussing PHI with patients, doctors or staff where other patients can overhear your conversation
• Check your waiting areas to ensure patients cannot overhear telephone conversations.
• When leaving messages for patients on a machine or with a person, keep the message brief do not divulge any confidential information and use good judgment. For example, a cancer clinic or drug rehabilitation facility should be very discreet, while a dentist or chiropractor may have less to worry about.
• When in doubt, ask the patient what he or she wants. For example, "When we get your lab results, how should we contact you?"
• When calling out patients in waiting rooms, limit the call out to the patients name only. Do Not mention the service they are there for. do not also mention their service. You can say, "Bob Jones? Come this way." Do not say, "Bob Jones? Ready for your chemo?" Do not ask, “What test are you here for today?” You can say, which physician ordered your test and when did they place the order.
• Discussions related to their test, procedure and/or treatment should be conducted in a private setting.

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