This document provides an overview of privacy training at Northwest Orthopaedic Surgeons (NWOS). It discusses NWOS's commitment to patient privacy and confidentiality. It outlines the course objectives of understanding how to properly handle private patient information and who can access it. Several case studies are presented that illustrate common examples of privacy breaches, such as inappropriately sharing patient information with unauthorized individuals, accessing records without authorization, and losing private health information.

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NORTHWESTNORTHWEST
ORTHOPAEDICORTHOPAEDIC
SURGEONSSURGEONS
HIPAA GENERAL PRIVACYHIPAA GENERAL PRIVACY
- MODULE 1- MODULE 1

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Introduction
• NWOS has always treated Privacy and
Confidentiality as a priority.
• In this course, you will learn about NWOS’s
privacy policies and procedures.
• You are required to complete privacy training
every year.
• All NWOS workforce members must comply
with our privacy policies and procedures.
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Course Objectives
After completing this course, you should
understand:
– That privacy is your responsibility!
– How you can recognize situations where sensitive
information may be handled improperly.
– How you can protect patient and confidential
information in common workplace situations..
– That you will be held responsible for improperly
handling sensitive information.

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To meet the objectives of this course, we will
visit several areas of a fictional but typical
healthcare system.

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NWOSNWOS
• A Day at the clinicA Day at the clinic

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This morning, at a healthcare facility very
much like ours . . .

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Sharing Information With Persons
Not Involved in Care
Janice, a hospital clinic employee, was in a car
accident and brought by ambulance to the ER.
Her friends Tamika, Mary and Dr. Drake also
work there.
Janice is being wheeled into the ER on a
stretcher.
Did the ER/Mary follow proper procedures in
releasing information to Tamika?

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Sharing Information With Persons
Not Involved in Care
No! The ER/Mary should have first checked to
see if Janice wanted the information shared and
if not, only have answered “Janice is in fair
condition”. Cont..So Tamika goes to the ER…

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Accessing InformationAccessing Information
What would you do? Have you ever seen this
done?
Should Tamika have read Janice’s chart?

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Accessing Information
No! Since Tamika was not directly involved in
Janice’s care, she should not have looked at
her friend’s chart, even though Tamika is a
hospital employee.

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Sharing Information with Family
and Friends
Joe Bacon, who is a recent college graduate,
has been admitted to the ER from the ASC for
treatment. He “opted out” of communications
with family and friends and specifically indicated
that nothing about his condition or treatment
was to be discussed with his parents.

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Sharing Information with Family
and Friends
Unable to learn what is happening with their son
through the ER, Mr. & Mrs. Bacon ask their
friend, Dr. Bart, who works at the ASC but, isn’t
involved in Joe’s care, to review Joe’s records.
Dr. Bart reviews the records and informs Joe’s
parents that Joe has hepatitis B and shows
signs of drug abuse.
Were proper procedures followed when
sharing information with Joe’s parents?

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No! Joe’s parents should not have received
information about Joe’s condition because he
had “opted out” of sharing information with
family and friends. This information is also
protected under WAC 246-08-400 and
RCW70.96A. Which do not allow this disclosure
without specific written consent from the patient.
In addition, Dr. Bart should not have reviewed
Joe’s records unless he was directly involved in
Joe’s medical care.
Sharing Information with Family
and Friends

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Inappropriate Disclosure
Passing through a crowded check-in area,
Nurse Betty overhears Brandy (the clinic check-
in clerk) telling a patient on the phone that he
needs a follow-up appointment because his HIV
test just came back positive. She notices
waiting patients listening intently to the
conversation.
Is Brandy taking the proper precautions?

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No! Brandy should have done at least one of
the following:
– Spoken in a lower voice in order not to be
overheard by the other patients.
– Waited until the clinic check-in area was less
crowded.
– Moved to another, more private area prior to
making the call.
Inappropriate Disclosure

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Inappropriate Use and Disposal
• On her way to get a patient from the waiting room,On her way to get a patient from the waiting room,
Nurse Shrene is approached by Dr. Maize, whoNurse Shrene is approached by Dr. Maize, who
hurriedly sticks a note in her hand before going tohurriedly sticks a note in her hand before going to
another exam room. Shrene is a bit surprised to seeanother exam room. Shrene is a bit surprised to see
that an invitation for drink and dinner is written on thethat an invitation for drink and dinner is written on the
back of a patient’s lab report.back of a patient’s lab report.
• ““Really!?” Shrene thinks to herself before throwingReally!?” Shrene thinks to herself before throwing
the crumpled note into the nearest trash bin.the crumpled note into the nearest trash bin.
What’s wrong with this scenario?

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Inappropriate Use and Disposal
Dr. Maize should have:
– NOT used a document containing personal patient
information for his own personal notes
– NOT given patient information to a co-worker who
wasn’t involved in the patient’s care.
Nurse Shrene should have:
– Disposed of the paper appropriately (for instance,
in a shredder or confidential disposal bin).

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Inappropriate Disclosure in a
Public Area
Katherine (an Accounts Payable clerk) steps
into the ASC waiting area and is surprised to
overhear a nurse and a doctor discussing the
potential transfer of a cardiac patient named
Rupert Survivor.
What should Katherine do?

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Inappropriate Disclosure in a
Public Area
Katherine should remind the doctor and nurse
that this information is confidential and should
not be discussed in a public area.

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Lost PHI and Inappropriate
Access
Colby, an environmental services employee
working in a hallway after hours, finds a piece of
paper lying on the floor. Upon examination, he
discovers that it is a lab report containing the
name of his favorite Dixie Chick, so he calls his
co-worker, Matt, over to take a look at it. . . .
What’s wrong with this scenario?

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Lost PHI and Inappropriate
Access
• The lab report was left in a non-secure area
• Colby should NOT have read the report
• He should NOT have shared the information
with Matt
• He SHOULD have notified:
– His supervisor OR
– The Privacy Officer

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Incidental Disclosure
During rounds, Dr. Billow pulled the curtain
around Mrs. Stinkles’s bed and quietly
discussed her diagnosis and prognosis with her,
after checking that her roommate was not
present. However, her roommate returned to
her bed just in time to overhear the discussion.
When Mrs. Stinkles discovered that her
roommate had overheard the discussion, she
became very upset.
Did Dr. Billow handle the situation correctly?

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Incidental Disclosure
Yes! By pulling the curtain and speaking in a
low voice, Dr. Billow took the proper steps. The
roommate’s overhearing was an “incidental”
disclosure. These cannot always be prevented,
even with the appropriate safeguards.

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Summary
• You should consider ALL patient information
as confidential.
• It should ONLY be accessed by, and shared
with, authorized persons.
• It is YOUR responsibility to protect patient
information – and to report any breaches of
confidentiality.

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Resources
For more information:
NWOS Privacy Policies & Guidelines
The NWOS Privacy Officer