Patient anonymity is a core HIM responsibility
February 1, 1998 2 minutes read
Patient anonymity is a core HIM responsibility
Restrict access to computerized patient records
Enterprisewide computer systems offer instant, even lifesaving access to patient information, and as more health care providers link together with integrated health care systems, that access will continue to expand. But better access to patient information comes at the price of less patient anonymity, as more entities are able to access patient medical records via integrated computer systems.It is a core responsibility of health information management professionals to protect that anonymity, Harry B. Rhodes, MBA, RRA, American Health Information Management Association (AHIMA) professional practice manager writes in the November/December issue of the Journal of AHIMA.
"The underlying axiom of a facility’s patient anonymity policy should be that the patient has the option to expressly state that he or she does not want any information, including confirmation of his/her presence in the facility, released,’" Rhodes writes.
Exceptions include those circumstances where health care facilities are required by law to report certain information to designated public officials, such as traffic accidents, fires, violent crimes, abuse, and arrests.
Set up policies to ensure anonymity
Health care facilities can implement several policies, Rhodes writes, to ensure patient anonymity under routine circumstances, such as the following:4 Omit patients’ names from the record covers.
4 Use alphanumeric codes or alias names in place of patients’ real name.
4 Replace patients’ names with alphanumeric codes or alias names on all bed boards, bulletin boards, and patient room signs.
4 Restrict computer system access to those users who need to know patients’ identities in order perform their jobs.
4 Place warning messages on the access screens of all patients who request anonymity.
4 Designate one individual responsible for controlling access restricted medical records in facilities with paper record systems.
4 Employ mechanisms that will lock out users who attempt to access information beyond their security clearances.
4 Perform periodic audits to ensure that organizational policies are being followed and are effective.
4 Employ mechanisms that will alert facility security officers when system users attempt access information beyond their security clearances.
4 Develop written policies outlining access to patient information.
4 Provide specific training about the responsibility to protect patient anonymity.
4 Require that employees sign nondisclosure agreements.
4 After discharge, limit access records during the chart completion process.
4 Also limit access charts after their completion.
4 At discharge, place patients’ actual names in master patient indexes with crosswalk software applications the aliases.
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