Tracking Disclosures

All individuals that make disclosures required by law (e.g., child abuse and neglect, adult protective services reporting, disclosures related to governmental audits, research related disclosures) must directly enter disclosure information into LLEAP Quick Disclosures by following the instructions outlined below and in the LLEAP Tip Sheet .

The identity of the individual/staff member making the disclosures and documenting them in LLEAP Quick Disclosures is protected as the Accounting of Disclosures report provided to patients at their request does not contain the name of the individual/staff member who made the disclosure. 

Disclosures occur whenever PHI is shared with a person or organization that is not part of the Loma Linda University Health (LLUH) Organized Healthcare Arrangement (OHCA). Refer to the list of entities under LLUH OHCA on page 12 of the Notice of Privacy Practices.

All patient requests for an Accounting of Disclosures must be referred to the HIM department.

Who needs access to LLEAP Quick Disclosures?

1. HIM/Medical Records - All medical record offices at each entity must have access to enter disclosures and a selected few within the department must have reporting access to fulfill patient requests for an accounting of disclosure made of their information.
2. Any department or individual that can identify themselves as disclosing information mandated by law.

Please notice: The ability to run accounting of disclosures reports will only be given to a limited number of individuals within HIM/Medical Records department.

Following is a list of the types of disclosures that must be tracked in LLEAP Quick Disclosures:

• Disclosures about victims of abuse, neglect, or domestic violence
• Disclosures for judicial and administrative proceedings
• Disclosures for law enforcement purposes
• Disclosures for public health activities (OSHPD, other state authorized and local health agencies, including public health authority authorized by law to receive reports of child abuse or neglect)
• Disclosures for health oversight activities (i.e., HHS' Office of Civil Rights, FDA e.g. Quality, safety or effectiveness of a product or activity regulated by the FDA, OSHA)
• Disclosures about decedents to coroners, medical examiners and funeral directors
• Disclosures for cadaverous organ, eye and tissue donation purposes
• Disclosures for research purposes under an IRB waiver (exempt status)
• Disclosures for research on decedent’s PHI
• Disclosures to avert a serious threat to health and safety
• Disclosures related to Military and veterans activities
• Disclosures related to Protective services for the President and others
• Disclosures related to Medical suitability determinations (for security clearance)
• Disclosures for workers' compensation
• Disclosures related to HHS investigations to determine the covered entity's compliance [160.310 and 164.502(a)(2)]

Certain disclosures permitted under the Privacy Rule, such as disclosures made pursuant to a subpoena or court order, typically must be made only by the HIM Department. Forward these requests to the HIM Department for processing as specific requirements conditioning the disclosure may apply.

How do you access LLEAP Quick Disclosures?

Once logged into LLEAP, open the chart of the patient who had the information disclosed and select Quick Disclosure from the left panel of the screen. Alternatively, you may access it by going to EPIC>Tools>Quick Disclosure and then selecting the patient. Refer to the LLEAP Tip Sheet for more information.

What if you have a large amount of disclosures to make at once?

Submit a RITM in ServiceNow asking “App Services: HIM” for a bulk import.

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