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  1. 1. Patient Health Information (PHI) must not be improperly disclosed. Say no to unauthorized requests for PHI. Make sure those passing by don't see PHI.
  2. 2. Patient Confidentiality 101 Health Insurance Portability and Accountability Act (HIPAA) Basics Why is Confidentiality Important? Hospital’s Confidentiality Policy What is a Breach of Confidentiality? Audits and Monitoring Process Reporting Violations Disciplinary Actions
  3. 3. HIPAA Basics  The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law 104-191) was designed to protect the privacy, confidentiality, and security of patient information.  HIPAA standards are applicable to all health information in all of its formats (e.g., electronic, paper, verbal). It applies to both electronically maintained and transmitted information.  HIPAA privacy standards include restrictions on access to individually identifiable health information and the use and disclosure of that information, as well as requirements for administrative activities such as training, compliance, and enforcement of HIPAA mandates. (Pozgar, 2012).
  4. 4. Why is confidentiality important  Confidentiality safeguards information that is gathered in the context of an intimate relationship.  It addresses the issue of how to keep information exchanged from being disclosed to third parties.  For example, confidentiality prevents physicians from disclosing information shared with them by a patient in the course of a physician– patient relationship.  Any unauthorized or inadvertent disclosures of data gained as part of an intimate relationship are breaches of confidentiality. (Nass, Levit & Gostin, 2009).
  5. 5.  Adhere to hospital’s policies on confidentiality privacy, at all times.  Access patient information only when information is required to perform your work.  Do not share or discuss patient information, unless it is necessary to perform your work.  Don’t ever share your identification number or password with anyone.  Log off your computer session when you are not by your workstation.  Ensure confidentiality when handling protected healthcare information.  All hospital employees will review the Privacy of Health Information (PDF) Booklet located in the hospital’s portal; complete the quiz at the end of booklet, and print certificate for inclusion in employee’s personal record.  All hospital employees will review, sign and return the Confidentiality Form (PDF), located in the hospital portal. Hospital’s Confidentiality poliCy (Confidentiality and Privacy of Patient Information, n.d.).
  6. 6.  A breach of confidentiality occurs when a disclosure is made to third party, without patient consent or court order, of private patient information that the physician has learned within the patient-physician relationship.  Disclosures can be oral or written, by telephone or fax, or electronically.  For example, via e-mail or health information networks. The medium is irrelevant, although special security requirements may apply to the electronic transfer of information. What is a breach of confidentiality? Patient Confidentiality, (n.d.).
  7. 7. AUDITS & MONITORING process  The hospital’s computer systems records all of your system activities.  The information you view and access using your account leaves a digital trail of information, which includes where you go and what you do.  The system audits and monitors access to confidential patient information on a regular basis; only access information required to perform your job.  All employees will be held accountable for unauthorized access to confidential information. (Protecting Patient Confidentiality and Security, 2011).
  8. 8. Reporting violations  If you witness or suspect a confidentiality violation of a patient’s health information, you must report it immediately to your supervisor.  Other reporting means include:  Hospital’s privacy office (email: or call 667-6726).  Hospital’s Security office (email: or call 667-7363).  Hospital’s Quality Assurance( email: or call 667- 8272.  You may also report violations anonymously, via the hospital’s Hotline,  at 677-4444).  REMEMBER: Reporting is everyone’s responsibility! (Protecting Patient Confidentiality and Security, 2011).
  9. 9. Disciplinary actions Unauthorized Access equals Termination of employment
  10. 10. References Confidentiality and Privacy of Patient Information. (n.d.). Medical College of Wisconsin. Retrieved 2013, from Patient Confidentiality. (n.d.). American Medical Association. Retrieved 2013, from http://www.ama- Pozgar, G. D. (2012). Legal aspects of health care administration (11th ed.). Sudbury, MA: Jones & Bartlett Learning. Protecting Patient Confidentiality and Security. (2011). Upstate Medical University. Retrieved 2013, from Nass, S. J., Levit, L. A., & Gostin, L. O. (2009). Beyond the HIPAA Privacy Rule: Enhancing Privacy, Improving Health Through Research. National Center for Biotechnology Information. Retrieved 2013, from