Describe the importance of maintaining patient confidentiality and HIPAA guidelines when documenting and reporting patient care information, specifically how it applies to electronic health records.
Maintaining patient confidentiality and adhering to the Health Insurance Portability and Accountability Act (HIPAA) guidelines are absolutely essential aspects of healthcare, particularly when documenting and reporting patient care information. This responsibility is even more critical when using electronic health records (EHRs), due to the increased accessibility and potential for breaches. HIPAA is a federal law that protects patient’s sensitive health information from being disclosed without their consent or knowledge. Confidentiality means that any personal or health information about a patient should not be shared or discussed with anyone who does not have a need to know it.
The primary importance of maintaining confidentiality is to protect patient privacy and trust. Patients share intimate details about their health with the understanding that this information will be kept private and used only for the purpose of providing care. Breaching this trust can lead to significant harm, including embarrassment, discrimination, loss of employment, and even reluctance to seek future medical care. Upholding confidentiality fosters a safe and respectful environment for patients to openly share their health concerns and receive necessary medical attention. For example, if a patient is receiving care for a condition that they wish to keep private, it is your ethical and legal responsibility to keep that information private and confidential.
HIPAA guidelines mandate that healthcare providers, including Certified Nursing Assistants (CNAs), must take specific steps to protect the privacy and security of patients' protected health information (PHI). PHI includes any information that can identify an individual patient, such as their name, address, social security number, medical history, current health status, treatment plans, and billing information. Access to PHI should be limited to only those individuals who need it to perform their job duties. CNAs should access only the minimum necessary PHI required for their responsibilities and should not seek out information they do not need. For example, if you are not providing care to a particular patient, you should not access their information in the EHR, even if they are a friend, or a family member. You should only access information of patients that you are assigned to.
When documenting in EHRs, specific HIPAA guidelines must be followed. Always log in to the system using a unique username and password, and never share these credentials with anyone else. Avoid leaving your computer unlocked or unattended while logged into the EHR system. Log out of the system completely when finished documenting to prevent unauthorized access by others. Ensure the computer screen is not viewable by unauthorized individuals when you are documenting. For example, when you go to lunch, ensure your EHR session is logged out. Never leave your user credentials where another person can access them. If you are using a mobile device to document, ensure that device is securely stored when not in use.
Documentation in the EHR should be accurate, objective, and factual. Avoid personal opinions or biases, and use only approved medical terminology and abbreviations. Do not include any unnecessary information. Record only relevant and necessary information pertaining to the patient’s care. Ensure that all entries are made promptly and are dated and timed correctly. If you make an error while documenting, follow established protocols for correcting errors without deleting the original entry, but correcting the information. For example, if you mistakenly enter an incorrect blood pressure reading, the correct entry must be added, without erasing the original, incorrect entry.
When reporting patient information, it should only be shared with other healthcare professionals who are directly involved in the patient’s care. Discussions about patient information, even with other staff members, should take place in a private and secure location. Avoid discussing patient information in public areas such as hallways, elevators, cafeterias, or public transportation. Be cautious when discussing patient information over the telephone or through electronic messaging, as these methods can be intercepted or overheard. Do not discuss patient information with family members or friends without the patient’s explicit consent. For example, if you are reporting patient information to another staff member over the phone, make sure you are in a private area where others cannot overhear you. If a patient's family member requests information, refer them to the nurse or the physician.
Be particularly careful when communicating PHI through email or other electronic methods. Ensure that any email messages are encrypted and that only authorized individuals have access. Avoid using personal email accounts, or other non-approved communication devices, to share PHI. Do not use social media to discuss patient information or photos, even if you do not mention any identifying information. Even if you do not use the patient’s name, photographs and other specific descriptions might still identify the patient. For example, do not communicate PHI through personal email, or messaging or social media platforms.
In the case of a suspected HIPAA breach, report it to your supervisor or the designated HIPAA officer at your facility immediately. Follow facility guidelines regarding how to report possible breaches of information. Be sure to document all details surrounding the breach, including who was involved, the date and time, and the information that may have been exposed. Always be proactive about protecting patient information. It's everyone’s responsibility to keep patient information safe.
In summary, maintaining patient confidentiality and adhering to HIPAA guidelines is crucial when documenting and reporting patient care information in EHRs. It involves limiting access to PHI, using secure methods for documentation and communication, and reporting any potential breaches promptly. Protecting patient privacy and confidentiality is not only a legal obligation but also an ethical responsibility that supports patient trust, ensures quality healthcare delivery, and prevents potentially serious harm.