Reasonable Safeguards Checklist and Audit Form

REASONABLE SAFEGUARDS CHECKLIST AND AUDIT FORM

YES NO

  Appointment reminders –Only the minimum necessary is used when leaving messages on answering machines or with family members when reminding patient of their appointments.

YES NO

  Test results – Only call back information is left on an answering machine or with a family member of the patient.

YES NO

  Mail –Only shows the minimum necessary information in the window (name, and address).

YES NO

  Appointment reminder postcards – Only the patients name, address, time, date of the appointment, and the patient’s doctor is placed on reminder cards.

YES NO

  Sign-in sheets – Only the patients name, time of appointment, time of arrival, and the patient’s doctor is on the sign-in sheet.

YES NO

  Medical charts on exam room doors are turned inward so they do not have any visible information.

YES NO

  Conversation in the halls – We talk quietly, do not use the full name of the patient if it is not needed, and always use the “minimum necessary” when discussing PHI in public places.

YES NO

  Public announcement system – We limit the information disclosed over a facility’s public announcement system to the minimum necessary. If addition information is needed, we refer them to a nurse’s station, etc.

YES NO

  Signs – We have signs that restrict patient access to particular areas and to remind employees about confidentiality.

YES NO

  Fax machine – Our fax machine is in a secure location and the “fax disclaimer” is on all outgoing faxes.

YES NO

  E-mail – The “e-mail disclaimer” is on all outgoing e-mails.

YES NO

  Telephone answering machine – Our machine is placed in a private location so that the patients waiting near by can not hear the messages when they are being retrieved.

YES NO

  Computer screens – Our computer screens are turned away from the patient’s view.

Provided By HCSI

YES NO

  Screen savers –Screen savers are set to go on after a short period of inactivity.

YES NO

  Leaving the computer – Nobody in our office leaves his or her computer unattended while PHI is being displayed on screen.

YES NO

  Passwords – Passwords are assigned only to those that have access to PHI on the computers.

YES NO

  Files – Our files are in a secure location, not accessible to unauthorized individuals.

YES NO

  Open filing systems – Our files are monitored at all times.

YES NO

  Marked Confidential - The outside of our files are marked with a confidential sticker or stamp.

YES NO

  Medical Records – Our medical records are set face down when not in use.

YES NO

  Patient desk – Our patients stand a few feet back from the counter used for patient counseling.

YES NO

  Mail – All correspondence that is received or is sent from our office that contains PHI is marked confidential.

YES NO

  Call verification – Our staff uses call verification to ensure that PHI is not disclosed to unauthorized individuals.

YES NO

  Destroying PHI – We properly dispose of (shredding/destroying) medical records and other PHI.

YES NO

  Web sites – Our Notice of Privacy Practices is on our web site and there is no way to access any PHI on that site.

Compliance Officer Name (Type/Print)

Compliance Officer SignatureDate

Provided By HCSI