Confidentiality Procedures
As you read 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 read 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.
• 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.
• 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 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
1. Determine all of the steps required. Use only the minimum number needed for carrying out the procedure.
2. Determine the best sequence for the performance of these steps. Those which are similar or closely related to each other should be grouped together.
3. Begin each step or procedure statement with an ACTION VERB such as: File, Organize, Take, Review, Code, Write, Enter, Stack, Call, Complete, Place, Meet
4. Review procedures which might be affected by changes in other procedures.
5. Test a procedure before putting it into everyday use; try to discover its flaws.
6. 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 improvement.