CentralMaineMedicalFamily
AdministrativePolicyNo. CMMF·GA-1026(R1) GeneralAdministrative
SUBJECT: ConfidentialityofPatientInformationandOtherInformation
I.PatientInformation
Ourpatientshavearighttoprivacy;arightto controlthereleaseoftheir information;tobefreeofunwarrantedpublicity;andtoknowtheirinformationwill notbedisclosedwithouttheirauthorization.
Allpatientinformation,providedduringanycourseofcareisconsidered privilegedcommunication.Thisprivilegedcommunicationandtheinformation securedasaresultbindsthe professionals/healthcareprovidersfrom unauthorizeddisclosure.
Suchinformationisconsideredstrictlyconfidentialandprivate.Allemployees mustrecognizetheirprofessionalandlegalresponsibilitiestoprevent unauthorizeddisclosure.Anyunauthorizeddisclosurescouldseriouslyimpairour abilitytofulfillpatientcareobligations.
A.Allemployeesareresponsibleforprotectingtheconfidentialityofourpatients' information.Anydisclosureofpatientinformationbetweenemployeesshallbe strictlylimitedtowhattheyneedtoknowtofulfill theirjobresponsibilities.Any disclosureofpatientspecificinformationshallbestrictlylimitedtowhatis requiredtofulfillthepurpose(s)statedonthepatient'sor his/herlegal guardian/representative'swrittenauthorizationorasmandatedbylaw.
B.Disclosureofpatientinformationshallbeaspermittedby StateandFederallaw.
Thepatientorhis/herlegalrepresentativecontrolsdisclosureofhis/her informationviawrittenauthorization(verbalauthorizationmaybeacceptablein specialcircumstancessuchasemergencysituationsutilizingthecallback methodpriortoreleasinganyinformation).Itisrecognizedthatmandatory disclosuresofpatientinformationmustoccurasperStateandFederal requirements.
C.Releaseofinformationtothe mediashallbemanagedbyauthorized administrative CMMF representatives(seeReleaseofInformationtotheMedia, HC-GA-1021).
D.ReleaseofInformation:
Confidentiality ofPatientInformationandOtherInformationCMMF-GA-1026(R1) Page1of6
1.ReleaseofinformationfromCMMFmedicalrecordsofprevioustreatment istobemanagedbyHealthInformationManagement(seeOwnershipof theMedicalRecordandReleaseofInformation,MC-PA-2031)andany requestregardingpriorpatientcareshallbereferredtothatDepartment andwillbeprocessedaccordingtoapproveddepartmentalpoliciesand procedures.
2.ReleaseofinformationfromCMMFmedicalrecordswillbemanagedby theappropriateofficesaccordingtothepractices'policiesand procedures.
E.Requestsbypatients,familymembers,orothersforinformationfromapatient's medicalrecordduringthecourseoftreatmentwillbereferredtotheattending physicianorprimarycareprovider.Otherrequestedpatientinformationwillbe referredtotheappropriateorganizational representative.
F.Toensuresecurityofconfidentialpatientinformation,thefollowingguidelines apply:
•Paperinformationshouldbeunderthedirectvisualsupervisionofappropriate staffatalltimes.
•Whenapatientrequeststoreviewhis/hermedicalrecord,theappropriate physicianwillbenotifiedandanorganizationalstaffrepresentativewillbe designatedtobepresentduringthisreview;requeststoreviewotherpatient informationwillbereferredtotheappropriateorganizationalrepresentative.
•Informationappearingoncomputerscreenswillbeprotectedbytheuser wheneverpossiblebysigningoffbeforeleavingtheworkstation;additionally, precautionsshouldbetakenbytheusertopreventunauthorizedviewingof confidentialinformationappearingonthescreenbyusingprivacyscreensas appropriate.
•ElectronicDistributionofInformation(e.g.,internale-mail,FAX,filetransfer, etc.)Willbepermittedasauthorizedbydepartmentalpoliciesand procedures.
G.Alldiscussionsconcerningpatientsshouldbeheldinprivateareaswherethese conversationscannotbeoverheard,andshouldberestrictedtothoseindividuals needinginformationtofulfillspecificjobresponsibilitiesforpatientcare.
H.InsituationsinvolvingStateof Maineand/orfederallyorlocallymandated reporting,reportsshallbemadeasrequiredbylaw.StandingOrderscovering thesesituationsincludebutarenotlimitedto:
ReportingNotifiableDiseasesinPatientsandStaff
AbusedorNeglectedChildren
MC-PA-2015ReportingCases ofAdultAbuse
Gunshotwounds
HC-PA-2019 Medical Examiner Cases StatewideCancer Registry Data Dog Bites
II.ExpectationsforMaintainingConfidentiality
A.Thefollowingtypesofinformationwillbetreatedasconfidentialandheldtothe samestandardwithregardstoaccessandreleaseaspatientinformation:
oPhysicianinformation(peerreview, credentialing,performanceimprovement, utilizationmanagement, etc.).
oHumanResourceandanyemployeeinformation,etc.
oFinancial;reimbursement,payer,etc.
oRegulatoryagencies'compliance/reports,includingresponsestosame.
oMarketingandanyorganizationalplanninginitiatives/activities.
oCommitteesandothermeetingsactivities/exchanges,
B.UponreceiptofwrittenorelectronicauthorizationfromaManager,accessto confidentialinformationonthecomputersystemwillberestrictedandgrantedby theneedtoknowasdefinedinthisS.O. Allpasswordsandaccesscodesare confidentialandarenottobedisclosedorusedbyanyoneotherthanthe individualtowhomtheywereassigned.
C.Anybreachofconfidentialitywillresultindisciplinaryaction,possiblyincluding terminationofemployment.
D.Allemployeeswillbemadeawareoftheirresponsibilitiesbyreviewingthispolicy andwillacknowledgetheseresponsibilitiesinwriting.
E.Atthetimeofinitialemploymentandannually,allemployeeswillsign the
"ConfidentialityStatementfor CentralMaineMedicalFamily"(attached).
Note:Administrativeandmanagerialsupportiscriticalinaddressingtheabove issues.
CrossReference:
ConfidentialityofPatientInformationandOtherInformationCMMF-GA-1026(R1) Page3of6
GuidingConceptsforPatientCareandBusinessPractice,HC-GA-1001
ReleaseofClinicalInformation,RH-GA-1114
PeterE.Chalke PresidentandCEO (SignatureonFile)
Effective:October6,2005
Supersedes:CMMCS.O.1:1.30(R3)
OrganizationalConfidentiality,RH-GA-1109
Revised:October23,2008
Reviewed:
AddendumtoConfidentialityofPatientInformationandOtherInformation
ConfidentialityStatementforCentralMaineMedicalFamily
AsanemployeeofCentralMaineMedicalFamily(includingsubsidiarycorporations),youwill haveaccesstoconfidentialinformationrelatedtoyoursubsidiarycorporationandotherswithin oursystem.Thepurposeof thisstatementisto assistyouinunderstandingwhatinformationis confidential andhowconfidentialinformationshouldbetreated.
WhatisConfidentialInformation?
1.PatientInformation
Allinformationconcerningour employees,patientsorcustomersisconfidential,evenif thatpersonisyourfamilymember,relative,friendorneighbor.Forexample,the simple factthatanindividualisapatientanywherewithinourorganizationisconfidential information.
2.OtherInformation
Allinformationrelatedtothe financesof theorganization,includingpricing,statisticsor departmentbudgetsisconfidential.
Allinformationcontainedinour employees'personnelrecordsorourphysicians' credentialingrecordsis confidential.Requestsforanyinformationconcerningemployees (includingroutineverificationofemployment)shouldalwaysbedirectedtoHuman ResourcesandinformationconcerningphysiciansshouldbedirectedtoMedicalAffairs.
Allinformationconcerningourcomputersystems(includingaccesscodesand passwords),strategicplans,internalcommunicationsandsimilar information is confidential.
AGOODRULETOFOLLOW:IFYOUARENOTCERTAINTHATCERTAIN INFORMATION ISCONFIDENTIAL,TREATITASTHOUGH ITIS.
HowshouldConfidentialInformationbetreated?
Confidentialinformationshouldneverbeaccessedbyorsharedwithanyone,includinganother employee,whodoesnothavealegitimatejob relatedanddescribedneedtoknowit.
Confidentialinformationshouldnotbeleftinreadilyaccessibleareasorinanunattended manner.Confidentialinformationshouldalwaysbesecuredandunderappropriatesupervision.
Confidentialinformationshouldneverbesharedoutsidetheorganizationunlessexpressly authorizedinwriting,approvedbyyourmanagerand yourjobrequiressuchinformation exchange.
Confidentialinformationmustneverbeopenlydiscussedinanypublicplace(suchashallways, elevators,diningareas,stairwells,etc.)withintheorganizationorinanypubliclocationoutside theorganization. Alwaysbecertainthatanydiscussionsinvolvingconfidentialinformationare heardonlybythosewhohavealegitimate,job-relatedneedtoknowtheinformation. Becareful ofwhoiswithinearshotandthusmaybeabletohear.
AddendumtoConfidentialityofPatientInformationandOtherInformation
Whataremyexpectationsasan employee?
•Accessinformationonlywhenyouhavealegitimatejob-relatedneedtoknowit.
•Employeesmaynotaccesstheirownchart.Allrequests,signedauthorizationforms, forcopiesofchartsshouldbesubmittedtotheHealthInformationManagement department.
•Questionsconcerningyourcareshouldbedirectedtoyourdoctororthenurse involvedwithyourcare.
•Anemployeemaynotaccessmembersoftheirfamily'schartsoranyotherchart wheretheyarenotinvolvedinthepatient'sdirectcare.
. •Sharingorusingaccesscodesandpasswords isprohibitedandwillresultin disciplinaryactionwhichmayincludetermination
•Ifyoubelievethatanyconfidentialinformationhasbeenaccessedordisclosed inappropriately,ormisusedinanywayyoumustreportthattoyour supervisor/managerimmediately.
•Theprivacyofourpatientsisofutmostimportance.Theprivacyofourphysicians andemployees,aswellasthesuccessofourorganizationisvitallyimportant. Therefore,yourcontinuedemploymentisdependentonthewayyoutreatconfidential information.Ifyouaccess,discloseorinanywaymisuseanyconfidential information,youwillbedisciplinedandthatdisciplinemayincludeterminationof employment. Ifyouhaveanyquestionsatanytimeconcerningconfidentiality,please direct themtoyoursupervisor/manager.
•Allincidentsconcerningabreachofpatientconfidentialityareinvestigated.The appropriatedisciplinaryactionwillbetakenuptoandincludingimmediate terminationofemployment.
•Ifyouleavetheorganization,rememberthatwhatyoulearnedhereisconfidential.
Theorganization'sconfidentialinformationisproprietary.Thatmeansitis"owned"
bytheorganizationand cannotbesharedbyanyone,includingaformeremployee, withouttheorganization'swrittenconsent.
I have read, understand and agree to theabove: Yes ☐ No☐
By attaching your electronic signature, you agree and acknowledge your responsibility to abide by the policies and procedures contained in this document. Once signed, please save and email this document to your school liaison to keep on file.
Signature: Type your signature Date Signed: Enter Today’s date.
CheckCorporateEntity
_☐ CMMC☐_BH☐_RH ☐_Bolster_☐RumfordCommunityHome
☐CMMF☐_CMHV_☐CMCH_☐AHS