Re: Mentioning Patient's Name In A Dictation
From: Gail Waldby (gwaldby@willinet.net)
Wed Jan 7 12:31:25 2004
Dean, as I understand it, the HIPAA rules say you must tell the patient
every time you disclose their information to anyone they didn't give you
permission to disclose to, that is, when they sign the insurance forms,
they give permission to send their info to their insurer.
But if your state licensing bureau or homicide bureau or federal DEA,
just as examples, require you to divulge patient info to them, you are
supposed to tell the patient and document that you disclosed the info
and told the patient in the patient chart.
Sorry I couldn't think of less ominous places to disclose info to.
Gail Waldby, MD
Huron SD
Dean Huffman wrote:
> .
>
> I did not make myself clear. The name can be in the "Header" (i.e., at
> the top of the page), just NOT in the text.
>
> Medical records apparently sees a distinction there, but I do NOT see a
> distinction. There is no evidence that I know of that the text is
> separated from the header (and that is distributed to the general public
> downtown). It is one document. Anyway, there is usually enough
> information about a patient in the text that the patient can be
> identified anyway. If for example it says a "34 year old 400 lb black
> female EDD 2/2/04 with twins by IVF...", then that narrows down the
> possibilities pretty well, even without the name, and many people could
> figure out who the patient is (by the way, I made up that patient
> discription -- that is not a real patient).
>
> I have checked with two other hospitals. Both of them said that the
> medical records department can make a rule that the patient's name not
> appear in the text if they, but if they blame it on HIPPA, they are
> either idiots or they are lying. I plan to call ACOG later on this and
> see if they have any opinion.
>
> By the way, what does one do about other documents, such as prenatal
> records, records from other hospitals if the patient is transferred,
> etc., that have the patient's name already on the documents. Do we have
> to put these documents in the shreader? If the patient's name is NOT on
> the documents, how do we know that we have the CORRECT patient?
>
> As an aside, this DOES bring up an interesting issue, however. About a
> year (mabye two or more) ago, the Green Journal had an interesting piece
> about a case report of back surgery on a Senator who had Addison's
> disease. They pointed out it would not be very difficult for anybody to
> figure out that it was John Kennedy. (But I am not planning on reporting
> the case of the ficticous 400 lb black female.)
>
> - - - -
>
>>>>mborn@massmed.org 01/07/04 9:37 AM >>>
>
> Dean
> Your Medical record Department is crazy; HIPAA says you cannot release
> Patient specific information to people who are not involved in the care
> of
> the patient, which means 3rd parties. If the diction is part of the
> hospital record then the patient's name needs to be in the dictation.
> If
> you are sending a letter to the referring physician, how will that
> physician
> know who the letter is about if the name isn't in the dictation.
> Myer
>
> Myer S. Bornstein, MD, MMM, FACOG, FACPE, CPE
>
> -----Original Message-----
> From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Dean
> Huffman
> Sent: Wednesday, January 07, 2004 8:44 AM
> To: Multiple recipients of list OB-GYN-L
> Subject: Mentioning Patient's Name In A Dictation
>
> .
>
> Every time I do a dictation, when I mention the patient's name, the name
> is replaced by "the patient". Our medical records department tells me
> that any patient specific information must be removed from the body of
> the dictation, by HIPPA regulations. Nevertheless, it appears on the
> header of the dictation.
>
> This seems stupid. The patient's vital signs, diagnosis, procedures,
> etc., may also allow for identification of the patient. If information
> related to the patient were removed, the discharge summary would
> probably have to say something like,
>
> "The patient was admitted for his/her condition, procedures might have
> been done, and he/she was discharged with a diagnosis."
>
> Does anybody know anything about this. Is there truly such a rule? It
> souunds crazy, but, on the other hand, government does a lot of crazy
> things.
>
> Because of HIPPA regulations, I am omitting my name from the body of
> this note.
>
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