HIPAA and Patient Medical Record Confidentiality
Federal civil rights laws and the Health Insurance Portability and Accountability Act (HIPAA)
Privacy Rule, together protect your fundamental rights of nondiscrimination and health
information privacy. Civil Rights help to protect you from unfair treatment or discrimination,
because of your race, color, national origin, disability, age, sex (gender), or religion. Federal
laws also provide conscience protections for health care providers.

The Privacy Rule protects the privacy of your health information; it says who can look at and
receives your health information, and also gives you specific rights over that information. In
addition, the Patient Safety Act and Rule establish a voluntary reporting system to enhance the
data available to assess and resolve patient safety and health care quality issues and provides
confidentiality protections for patient safety concerns.
Civil Rights                                 Health Information Privacy Rights
    OCR helps to protect you from                By enforcing the Privacy and Security
    discrimination in certain health care and    Rules, OCR helps to protect the privacy of
    social service programs. Some of these       your health information held by health
    programs may include:                        insurers and certain health care providers
                                                 and health insurers. Some of these providers
        Hospitals, health clinics, nursing       and insurers may include:
        homes
        Medicaid and Medicare agencies               Doctors and nurses
        Welfare programs                             Pharmacies
        Day care centers                             Hospitals, clinics, and nursing homes
        Doctors’ offices and pharmacies              Health insurance companies
        Children’s health programs                   Health maintenance organizations
        Alcohol and drug treatment centers           (HMOs)
        Adoption agencies                            Employer group health plans
        Mental health and developmental              Certain government programs that pay
        disabilities agencies                        for health care, such as Medicare and
                                                     Medicaid
    Learn more about civil rights>>
                                                 OCR also enforces the confidentiality
                                                 provisions of the Patient Safety Act and
                                                 Rule.

                                                 Learn more about health information
                                                 privacy>>




                             Health Information Privacy
The Office for Civil Rights enforces the HIPAA Privacy Rule, which protects the privacy of
individually identifiable health information; the HIPAA Security Rule, which sets national
standards for the security of electronic protected health information; and the confidentiality
provisions of the Patient Safety Rule, which protect identifiable information being used to
analyze patient safety events and improve patient safety.

The Standards for Privacy of Individually Identifiable Health Information (―Privacy Rule‖)
establishes, for the first time, a set of national standards for the protection of certain health
information. The U.S. Department of Health and Human Services (―HHS‖) issued the Privacy
Rule to implement the requirement of the Health Insurance Portability and Accountability Act of
1996 (―HIPAA‖).
The Privacy Rule
Standards address the use and disclosure of individuals’ health information—called ―protected
health information‖ by organizations subject to the Privacy Rule — called ―covered entities,‖ as
well as standards for individuals' privacy rights to understand and control how their health
information is used. Within HHS, the Office for Civil Rights (―OCR‖) has responsibility for
implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and
civil money penalties.

                    Organizational Policies and Regulations
       All staff members should have training at least annually on confidentiality especially
       when the staff has access to personal information; the training should include HIPAA
       rules and regulations. Staff should know that there can be serious ramifications for
       violating a patient’s privacy.

       All employees that have access to personal information should be required to attend the
       annual training. During the meeting they should be given an employee handbook that
       address confidentiality and the employees should sign a copy for their personnel file.

       Training should include a review of applicable Case Studies of various types of violations
       of medical record confidentiality and HIPAA regulations.

       Role playing exercises should be conducted to teach personnel what to do in the event
       they witness violations and misuse of patient records.

       Training should incorporate real life examples of potential confidentiality violations and
       how to avoid mistakes.

       A Privacy Officer should be used to monitor and to make sure that security measures are
       maintained, that all the applicable state and federal laws are enforced, and that all
       organizational policies and procedures are followed.


                                   Security Measures

       Background checks for all employees
       Limited Access to Records
       Login Authentication
       Monitor Login Frequency
       Maintain Chain-of-Custody
       List of all Personnel Associated with Patient Care
       Maintain Attendance Records
       Record Login Dates and Time
Record all Data Transfer Date and Time


                                     References

Summary of the HIPAA Privacy Rule (2012) – U. S. Department of Health and Human Services.
Retrieved June 28, 2012 from website:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

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  • 1.
    HIPAA and PatientMedical Record Confidentiality Federal civil rights laws and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, together protect your fundamental rights of nondiscrimination and health information privacy. Civil Rights help to protect you from unfair treatment or discrimination, because of your race, color, national origin, disability, age, sex (gender), or religion. Federal laws also provide conscience protections for health care providers. The Privacy Rule protects the privacy of your health information; it says who can look at and receives your health information, and also gives you specific rights over that information. In addition, the Patient Safety Act and Rule establish a voluntary reporting system to enhance the data available to assess and resolve patient safety and health care quality issues and provides confidentiality protections for patient safety concerns.
  • 2.
    Civil Rights Health Information Privacy Rights OCR helps to protect you from By enforcing the Privacy and Security discrimination in certain health care and Rules, OCR helps to protect the privacy of social service programs. Some of these your health information held by health programs may include: insurers and certain health care providers and health insurers. Some of these providers Hospitals, health clinics, nursing and insurers may include: homes Medicaid and Medicare agencies Doctors and nurses Welfare programs Pharmacies Day care centers Hospitals, clinics, and nursing homes Doctors’ offices and pharmacies Health insurance companies Children’s health programs Health maintenance organizations Alcohol and drug treatment centers (HMOs) Adoption agencies Employer group health plans Mental health and developmental Certain government programs that pay disabilities agencies for health care, such as Medicare and Medicaid Learn more about civil rights>> OCR also enforces the confidentiality provisions of the Patient Safety Act and Rule. Learn more about health information privacy>> Health Information Privacy The Office for Civil Rights enforces the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. The Standards for Privacy of Individually Identifiable Health Information (―Privacy Rule‖) establishes, for the first time, a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services (―HHS‖) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (―HIPAA‖).
  • 3.
    The Privacy Rule Standardsaddress the use and disclosure of individuals’ health information—called ―protected health information‖ by organizations subject to the Privacy Rule — called ―covered entities,‖ as well as standards for individuals' privacy rights to understand and control how their health information is used. Within HHS, the Office for Civil Rights (―OCR‖) has responsibility for implementing and enforcing the Privacy Rule with respect to voluntary compliance activities and civil money penalties. Organizational Policies and Regulations All staff members should have training at least annually on confidentiality especially when the staff has access to personal information; the training should include HIPAA rules and regulations. Staff should know that there can be serious ramifications for violating a patient’s privacy. All employees that have access to personal information should be required to attend the annual training. During the meeting they should be given an employee handbook that address confidentiality and the employees should sign a copy for their personnel file. Training should include a review of applicable Case Studies of various types of violations of medical record confidentiality and HIPAA regulations. Role playing exercises should be conducted to teach personnel what to do in the event they witness violations and misuse of patient records. Training should incorporate real life examples of potential confidentiality violations and how to avoid mistakes. A Privacy Officer should be used to monitor and to make sure that security measures are maintained, that all the applicable state and federal laws are enforced, and that all organizational policies and procedures are followed. Security Measures Background checks for all employees Limited Access to Records Login Authentication Monitor Login Frequency Maintain Chain-of-Custody List of all Personnel Associated with Patient Care Maintain Attendance Records Record Login Dates and Time
  • 4.
    Record all DataTransfer Date and Time References Summary of the HIPAA Privacy Rule (2012) – U. S. Department of Health and Human Services. Retrieved June 28, 2012 from website: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html