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1. Develop a release of information policy statement

Health Record Policies

working in a health information management department for an outpatient clinic.The manager is revising the policy and procedural manuals for the department and is particularly interested in confirming that policies are in compliance with state law and Health Insurance Portability and Accountability Act (HIPAA) Privacy Law.The manager asks to review several policies and to review state code as they apply to HIPAA Law.

The manager left the following two policies on a desk for review:

Release of Information: Shadow Chart Policy

“A shadow chart is a duplicate health record kept for the convenience of the medical provider. In the event that an authorized individual requests health information pertaining to a specific episode of care, health information management staff will review any shadow charts kept by medical providers for that patient to determine if any such shadow charts contain information related to the episode of care. If the shadow chart contains information related to the episode of care and is not found in the electronic record, the information from the shadow chart will also be copied, in addition to requested information found in the electronic record.”

The supervisor left a note that this policy needs an addendum.

Information Security: Workstation Policy

“Employees are required to secure their personal workstations when not in use. Confidential health information must not be displayed on computer screens unless the employee is performing work functions on the computer and using the information. Employees may not access another employee’s computer while it is in use nor may employees use another’s password for any reason. Violation of this policy will result in disciplinary action, and depending upon nature of violation, termination may result.”
. Requirements and procedures for patient’s examination and copying.

(1) Upon receipt of a written request from a patient to examine or copy all or part of the patient’s recorded health care information, a health care provider, as promptly as required under the circumstances but no later than 10 days after receiving the request, shall:

(a) make the information available to the patient for examination, without charge, during regular business hours or provide a copy, if requested, to the patient;

(b) inform the patient if the information does not exist or cannot be found;

(c) if the health care provider does not maintain a record of the information, inform the patient and provide the name and address, if known, of the health care provider who maintains the record;

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LEGAL & ETHICAL CONSIDERATIONS IN HEALTHCARE

Task:

A. Evaluate the two policies in the attached “Health Record Policies” by doing the following:

1. Discuss what information should be included in an addendum pertaining to a shadow chart.
2. Discuss how information technology staff can help decrease incidents of security breaches.

B. Discuss one situation from Montana Code 41-1-402 (2a through 2d) that may result in criminal liability to the organization if not followed.
1. Summarize how HIPAA defines criminal liability.
2. Explain which part of 2a through 2d of Montana Code 41-1-402 would directly impact actions of clinical staff.

C. Discuss one situation from Montana Code 50-16-603x (1 through 7) specific to health record identification that may result in a legal claim against the organization if not followed.

1. Develop a confidentiality policy statement (suggested length of 1–2 sentences) using either Montana Code 41-1-402 or Montana Code 50-16-603.

D. Compare three points in the Montana codes to HIPAA laws as they refer to release of information.

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