Confidentiality of Care
Policy & Procedure IV.3
The client has his or her right to expect that all aspects of care will be treated as confidential.
Registered nurses, nurse practitioners, physicians, and consultants giving direct care may read and enter data on the client's chart.
Privacy is established for clients when examining, interviewing, or sharing information by drawing the curtain or closing the door.
Verbalization of client's information is not shared with those not participating in the client's care.
Discretion is used in the exchange of client information on the telephone.
Discretion is used to maintain confidentiality during meetings.
All staff, student workers, and students doing clinical practicum will be asked to sign a confidentiality form.
Confidentiality of Medical Records
Policy & Procedure IV.4
Confidential information in the medical record is considered privileged information and cannot be released without the client’s written authorization. Confidentiality is to be broken only if the patient poses a danger to self or to others. Information is considered to be all diagnostic and clinical data.
The guarantee of confidentiality in a privileged relationship helps assure that the client will not withhold information critical to his/her care.
Those employees with access to medical information shall respect the doctrine of confidentiality and not divulge any information contained in the medical record unless they are authorized to do so by the client.
The release of information requires the client’s written authorization. This authorization can be obtained using our Permission for Release of Medical Information form.
Authorization is REQUIRED for the release of information to:
Physicians and nurse practitioners not on the Student Health Clinic staff who are not at that moment treating the client; Attorneys; Insurance Companies; Law enforcement agencies – without client consent, a court order or a search warrant is needed; Schools; Immigration and Naturalization Services; Employers; Welfare Agencies; Social Security Administration; Veterans Administration; Internal Revenue Service; Civil Service Department; Courts without a Subpoena Duces Tecum
Authorization is NOT REQUIRED for release of information to:
Another health care facility via telephone (after verification) when the information is needed for DIRECT EMERGENCY CARE of the client; Another physician or health care facility that is at that moment treating the client (after verification, ask that they send a valid authorization as soon as possible); State and local health departments and/or other agencies listed below (inform client in advance, if possible, that certain diseases may be reportable): Communicable Disease Control, Bureau of Maternity and Family Planning Services, State Department of Labor, Medical Examiner, Many third-party payers have clauses in their contracts that allow for release of information when the patient signs the contract. Request a copy of the signed consent from the insurance company before releasing information; Clients may request in person, via letter or via FAX that copies of immunization records be given or faxed to them or another institution. A copy of the signed request or signed “Permission for Release of Medical Information” form will be attached to information transmitted and kept on file by SHC or scanned into the EMR for not less than seven years. Refer to HIPAA of 1996.
Each member of the Student Health Clinic staff shall be required to read and sign a copy of the statement attached.