UTMB HANDBOOK OF OPERATING PROCEDURES

Section 6 Compliance Policies Subject 6.2 Privacy Related Policy 6.2.4 Use and Disclosure of PHI for Patient Directories

04/11/03 - Originated 07/06/07 -Reviewed w/ changes - Reviewed w/o changes Compliance Office - Author

Use and Disclosure of PHI for Patient Directories

Policy

UTMB, in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), maintains that patient information must be kept private and confidential. UTMB may use and disclose Protected Health Information (PHI) for the UTMB Patient Directory if the individual was informed in advance of the use or disclosure and had the opportunity to agree, prohibit, or restrict the disclosure. The agreement to use and disclose PHI from the UTMB Patient Directory may be oral. UTMB faculty, staff and students must document the agreement, prohibition, or restriction in the medical record. Violation of this policy may further result in disciplinary action up to and including termination for employees; a termination of employment relationship in the case of contractors or consultants; or suspension or expulsion in the case of a student. Additionally, individuals may be subject to loss of access privileges and civil and/or criminal prosecution.

Use and Disclosure for Patient Directories

Except when an objection is expressed, UTMB may use the following portions of the patient’s PHI that is maintained in the UTMB Patient Directory: a. The individual’s name; b. The individual’s location in the hospital; c. The individual’s condition described in general terms that do not communicate specific medical information about the individual; and d. The individual’s religious affiliation. UTMB may disclose patient directory information, as listed above, to members of the clergy even if the clergy member does not inquire about an individual by name. Disclosure of directory information, except for the individual’s religious affiliation, may be provided to other persons who ask for the individual by name. However, UTMB has the right to withhold some portions of the hospital’s patient directory information if UTMB, based upon professional judgment, determines that withholding portions of the directory information is in the patient’s best interest.

Opportunity to Object	UTMB must inform an individual of the information that may be included in UTMB’s Patient Directory and the persons to whom UTMB may disclose such information. However, if the individual objects to being included in the patient directory, UTMB must not include the patient’s information in the facility directory and allow the individual to become a “No-Information” patient.
”No-Information” Patients	“No Information” is a designation that can be requested by medical/nursing personnel, University Police or the patient or patient’s guardian. The patient will be designated “No Information” on the Health Care Information Systems (HIS) by Admitting personnel. If a patient, or his/her representative, requests a “no information” designation, a member of the Admitting staff will explain the “No Information” policies and regulations. Since UTMB will not be able to confirm that a “no information” patient has been admitted, this may mean UTMB will not provide the patient’s location for deliveries. Admitting personnel are available Monday - Friday 8 am to 5 pm to fully explain the impact of deciding to be a "no information patient".  All inquiries regarding Texas Department of Criminal Justice (TDCJ) patients will be referred to the TDCJ Warden to be disseminated through established TDCJ channels. After-hour requests should be routed to the duty officer through the hospital operator.
Providing Room Location to Visitors	In order to ensure that patient’s privacy rights are protected and to protect employees from wrongful allegations of breaches of patient privacy, all disclosures of patient room numbers should be provided by the UTMB Admitting Information Desk, even though an employee may have access to the information as part of their job responsibility. In order to balance providing the information with the patient’s right to privacy you should follow one of the steps below when approached for a room location: 1. Contact the information desk for the room number to provide the visitor; 2. Phone the patient room number yourself and allow the patient to provide the room number to the visitor, or 3. Escort the requestor to the information desk.
Emergency Circumstances	If the opportunity to object to being listed in the patient directory cannot practically be provided because of the individual’s incapacity or emergency treatment circumstance, UTMB may use or disclose some or all of the PHI for UTMB’s patient directory, if the disclosure is: 1. Consistent with a prior expressed preference of the individual, if any, is known to UTMB; or

Emergency Circumstances, continued	2. In the individual’s best interest as determined by UTMB, and in the exercise of professional judgment. However, UTMB must inform the individual and provide an opportunity to agree or object to the uses or disclosures for the patient directory as expressed above when it becomes practical to do so.
Reference	45 C.F.R §510 Policy 6.2.2