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1.
Staff
does not discuss confidential patient information among themselves
in public areas.
YES
NO
2.
Conversations
with the patient/family regarding confidential patient information
are not held in public areas.
YES
NO
3.
Overhead
and Intercom announcements do not include confidential patient
information.
YES
NO
4.
Phone
conversations and dictation are in areas where confidential patient
information cannot be overheard.
YES
NO
5.
Dictation
is completed in an area where confidential patient information
can not be overheard.
YES
NO
6.
Computer
monitors are positioned away from public areas to avoid observation
by visitors.
YES
NO
7.
The
screens on unattended computers are returned to the logon screen
or have a password enabled screen saver. Staff protects their
ID and password and never shares them, or the use of a workstation
while logged in.
YES
NO
8.
On
desks in public areas, chart holders or nurse's stations, documents
with confidential patient information are face down or concealed,
avoiding observation by patients or visitors.
YES
NO
9.
Paper
records and medical charts are stored or filed in such away as
to avoid observation by patients or visitors, or casual access
by unauthorized staff.
YES
NO
10.
Except
for the patient's name, confidential patient information is not
called out into the waiting room.
YES
NO
11.
Release
of confidential patient information is done by staff specifically
authorized to do so.
YES
NO
12.
Confidential
patient information is not left on an unattended printer, photocopier
or fax machine, unless these devices are in a secure area. Physical
access to fax machines and printers is limited to authorized staff.
YES
NO
13.
Confidential
patient information is discarded in the appropriate secure container
or shredded.
YES
NO
14.
Answering
machines volume is turned down so information being left cannot
be overhead by other staff or visitors. Voice mail passwords are
not the default settings, or the last four digits of your phone
number.
YES
NO
15.
Patient
Lists, including scheduled procedures, with information beyond
room assignments are not readily visible by patients or visitors.
YES
NO
16.
Visitors
and patients are appropriately escorted to ensure they do not
access staff areas, dictating rooms, chart storage, etc. Those
persons not recognized in restricted areas, are challenged for
identification.
YES
NO
17.
For
units that are not staffed 24 hours, patient records are filed
in locking storage cabinets or rooms that are locked.
YES
NO
18.
Only
authorized staff has access to confidential patient information,
and they access and use only the minimum amount necessary to accomplish
their duties. All staff wears the appropriate nametag at all times.
YES
NO
19.
All
supervisors regularly review institutional policies that are applicable
for their area work assignments with their staff, to insure that
current practices and procedures protect patient privacy.
YES
NO
20.
Staff
feel comfortable, and obligated, to report misuse of confidential
patient information to their supervisor, or to the UTMB hotline.
YES
NO
21.
Patient
shadow records/charts are inventoried in a database allowing our
department/clinic to generate a list of all the shadow records
we maintain.
YES
NO
22.
Our
department/clinic uses “out cards” or some system
to track patient shadow records/charts that are removed from the
file cabinets or shelves.
YES
NO
23.
When
documents containing patient information are thrown away, the
documents are being disposed of in recycle bags or shredded.
YES
NO
24.
Each
manager has assigned a staff member to be responsible for walking
around the department/clinic at the end of the day and picking
up and securing all patient information sitting out in open areas,
conference room or patient rooms.
YES
NO
25.
Fax
machines are located in a secure area where UTMB personnel are
monitoring patient information being sent through fax.
YES
NO
26.
Rolling
carts used by physicians and nurses when conducting rounds are
secured to prevent unauthorized access at night.
YES
NO
27.
Patient
charts hanging outside exam rooms are placed in a manner that
avoids disclosing the identity of the patient.
YES
NO
28.
Vendors
visiting departments/clinics including drug representatives and
medical equipment technicians are not given access to UTMB patient
information.
YES
NO
29.
Doors
to doctors and nurses’ offices are closed when unoccupied.
