As you reviewed the  RMC Policy and Procedure Manual  you may have noticed that the bullet point items for the  Confidentiality Procedures  do not comply with the way procedure steps should be written. Your task is to re-write each of the procedure steps. Update each of the procedure bullet points in  Confidentiality Procedures . The first one has been done for you here as an example: OLD: All persons employed at RMC having access to information concerning patients, such as volunteers, hospital staff members and physicians must hold all information in strict confidence, and shall abide by the Health Insurance Portability and Accountability Act (HIPAA) regulations. NEW:  Abide  by the Health Insurance Portability and Accountability Act (HIPAA) regulations. All persons employed at RMC having access to information concerning patients, such as volunteers, hospital staff members and physicians must hold all information in strict confidence. If you need to review the step see Writing Procedures on the  RMC Policy and Procedure Manual  page. SUBJECT:  CONFIDENTIALITY POLICY: It is the policy of RMC to maintain an individual’s right to privacy and confidentiality of information.  Information known or contained in the patient's medical record (known as protected health information) shall be treated as confidential and will be released in appropriate circumstances only with the written consent of the patient or legal guardian.  Information concerning patients, visitors and staff shall be managed with the highest degree of appropriateness and confidentiality, pursuant to organization-wide policies and procedures. PROCEDURE: · All persons employed at RMC having access to information concerning patients, such as volunteers, hospital staff members and physicians must hold all information in strict confidence, and shall abide by the Health Insurance Portability and Accountability Act (HIPAA) regulations. · Information concerning patients which may be considered ordinary facts and necessary for planning of specific care and services, will be handled with professional discretion and on a "need to know” basis. · Information regarding physicians, staff members or volunteers is to be relayed to others as appropriate to the related job function or task and/or to facilitate patient care and services only.  Information regarding physicians, staff members or volunteers is to be kept on a professional level, and only discussed in relationship to the individual’s purpose and function within the institution. · Requests for patient information will be directed to the Health Information Management Department.  Disposition of such requests will be in accordance with the hospital's established policy and procedure for Release of Information and pursuant to the HIPAA regulations. · Advances in technology will be reviewed as these are made available to the institution, to determine if these advances can be employed to improve privacy and confidentiality practices. .

1. As you reviewed the
RMC Policy and Procedure Manual
you may have noticed that the bullet point items for the
Confidentiality Procedures
do not comply with the way procedure steps should be written.
Your task is to re-write each of the procedure steps. Update
each of the procedure bullet points in
Confidentiality Procedures
. The first one has been done for you here as an example:
OLD: All persons employed at RMC having access to
information concerning patients, such as volunteers, hospital
staff members and physicians must hold all information in strict
confidence, and shall abide by the Health Insurance Portability
and Accountability Act (HIPAA) regulations.
NEW:
Abide
by the Health Insurance Portability and Accountability Act
(HIPAA) regulations. All persons employed at RMC having
access to information concerning patients, such as volunteers,
hospital staff members and physicians must hold all information
in strict confidence.
If you need to review the step see Writing Procedures on the
RMC Policy and Procedure Manual
page.
SUBJECT: CONFIDENTIALITY
POLICY:
It is the policy of RMC to maintain an individual’s right to
privacy and confidentiality of information. Information known
or contained in the patient's medical record (known as protected
health information) shall be treated as confidential and will be
released in appropriate circumstances only with the written
consent of the patient or legal guardian. Information

2. concerning patients, visitors and staff shall be managed with the
highest degree of appropriateness and confidentiality, pursuant
to organization-wide policies and procedures.
PROCEDURE:
·
All persons employed at RMC having access to information
concerning patients, such as volunteers, hospital staff members
and physicians must hold all information in strict confidence,
and shall abide by the Health Insurance Portability and
Accountability Act (HIPAA) regulations.
·
Information concerning patients which may be considered
ordinary facts and necessary for planning of specific care and
services, will be handled with professional discretion and on a
"need to know” basis.
·
Information regarding physicians, staff members or volunteers
is to be relayed to others as appropriate to the related job
function or task and/or to facilitate patient care and services
only. Information regarding physicians, staff members or
volunteers is to be kept on a professional level, and only
discussed in relationship to the individual’s purpose and
function within the institution.
·
Requests for patient information will be directed to the Health
Information Management Department. Disposition of such
requests will be in accordance with the hospital's established
policy and procedure for Release of Information and pursuant to
the HIPAA regulations.
·

3. Advances in technology will be reviewed as these are made
available to the institution, to determine if these advances can
be employed to improve privacy and confidentiality practices.
·
Personal opinions as to the competence of hospital staff
members or any staff members, are not to be expressed in a
public environment and should always be addressed to the staff
member's supervisor, hospital Chief Executive Officer or the
Chief of Staff for resolution.
·
At no time shall physicians, staff members, volunteers or others
associated with RMC engage in discussions of a personal nature
which are unrelated to the organization’s mission, values and
purpose (i.e., gossip).
·
At no time shall staff members, volunteers, or others associated
with SSMH, who have access to confidential patient or hospital
information, speak with the news media, or others outside the
hospital, without prior approval from hospital administration.
All encounters with the news media should be directed to
administration.
·
All staff will be educated and trained about the requirements for
information privacy and confidentiality appropriate for each
level of employee to carry out his/her healthcare function within
the hospital. Education and training includes orientation, initial
education and any ongoing education and training necessary
related to changes with this organization’s information
confidentiality and privacy practices.
·

4. Enforcement of the principles of this policy will be monitored
through the combined efforts of the Information Services
Director and the Risk Management Department. Monthly
monitoring of violations of this policy will be conducted with
quarterly reports submitted to the Performance Improvement
Committee and Governing Body.
·
Outcomes from monitoring activities will be analyzed to
determine if improvements can be made in privacy and
confidentiality practices.
Purpose
The policy and procedure manual provides employers,
managers, and employees with a systematic approach to
implementation of policies, plans, and work routines. A
properly developed manual can achieve the following benefits
for your organization:
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The RMC Policy and Procedure Manual
The healthcare industry uses written policies and procedures
very heavily. Most hospitals are accredited by JCAHO and are
required to have formal policies and procedures for every rule,
task, and activity that takes place in the hospital. It is common
to see rows and rows of large 3 ring binders in the Medical Staff
office, the Human Resource office, and near the CEO.
Each department within the hospital must also have their own
policy and procedure manuals that reflect the unique activities
within their department. You will need to read the policy

5. manual for Rasmussen Medical Center (RMC) that is provided
for you to understand how this HIM department functions and
how the tasks that you are about to complete over the next 11
weeks relate to how the department is managed.
RMC Policy and Procedure Manual
The RMC Policy and Procedure Manual
The healthcare industry uses written policies and procedures
very heavily. Most hospitals are accredited by JCAHO and are
required to have formal policies and procedures for every rule,
task, and activity that takes place in the hospital. It is common
to see rows and rows of large 3 ring binders in the Medical Staff
office, the Human Resource office, and near the CEO.
Each department within the hospital must also have their own
policy and procedure manuals that reflect the unique activities
within their department. You will need to read the policy
manual for Rasmussen Medical Center (RMC) that is provided
for you to understand how this HIM department functions and
how the tasks that you are about to complete over the next 11
weeks relate to how the department is managed.
RMC Policy and Procedure Manual
Writing Procedures
Determine all of the steps required. Use only the minimum
number needed for carrying out the procedure.
Determine the best sequence for the performance of these steps.
Those which are similar or closely related to each other should
be grouped together.
Begin each step or procedure statement with an ACTION VERB
such as: File, Organize, Take, Review, Code, Write, Enter,
Stack, Call, Complete, Place, Meet
Review procedures which might be affected by changes in other
procedures.
Test a procedure before putting it into everyday use; try to
discover its flaws.
Evaluate the procedure after it has been used for several weeks.
Employees who work with the procedure are good sources for
identifying its possible problems and offering suggestions for

6. improvement.