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Standards of Conduct

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General Compliance Guidelines

Patient condition reports. During regular business hours, the Office of University Advancement Public Affairs staff, (409) 772-2618, handles all calls from the media related to patient condition. After 5 p.m. weekdays and on weekends and holidays, call the UTMB operator at (409) 772-1011 and ask to page the nurse administrator.

A copy of the UTMB policy 9.2.4, Release of Patient Information to Family, Friends, Media may be accessed via the Internet at http://www.utmb.edu/policy/ihop/

Accuracy of records. Each of us is responsible for the integrity and accuracy of business documents and records. All records, whether of a medical, operational, or financial nature, should be maintained in accordance with applicable laws and policy. No one may alter or falsify information on any record or document. Making any false statement in a medical record that is used to support billing of medical services may be considered criminal fraud. Billings to third-party payers (government and private insurance payers) is an example of records that must be accurate and conform to appropriate laws and regulations.

Retention and disposal of records. We are required to maintain an active and continuing records management program that identifies vital and confidential records and ensures the appropriate retention and disposition of records. No employee should tamper with records, or remove or destroy them except in accordance with the approved retention and disposition policy. Questions about specific record retention requirements should be directed to UTMB’s Records Management Department at (409) 747-5900, or your department’s record management officer. All departments at UTMB must develop and maintain a record retention schedule. UTMB departments must adhere to the schedule.

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Q

A local news reporter calls to ask me questions about a meningitis patient who was admitted to the hospital through the Emergency Room. Who should answer the reporter’s questions?

A

The Office of University Advancement (OUA). During regular business hours, call (409) 772-2618, and the OUA staff will manage all calls from the media related to patient condition. After 5 p.m. weekdays and on weekends and holidays, call the UTMB operator at (409) 772-1011 and ask to page the nurse administrator and refer the reporter to the administrator.

Q

I saw my ex-husband’s wife in the hallway at UTMB. I believe she is being treated here. Can I look up her medical record to determine why she is here?

A

No. This is strictly forbidden. All medical information is private and must be held in the strictest confidence.

Q

My supervisor has asked me to change the date on a progress note on a patient chart so that we can submit a bill. Am I allowed to do that?

A

No. Once a document has been completed it may not be altered. An addendum may be made to the note, but the note should not be changed and the addendum must be dated with the date it is written.

Q

I am aware that an outside auditor is on the way to look over some of UTMB’s financial records. I am asked to immediately destroy several boxes of records. What should I do?

A

Once you are notified an auditor is coming to view certain records, do not destroy any records requested for review by the auditor. Each UTMB department has a formal record retention schedule that should be followed. The schedule includes appropriate times to destroy records. Just as records should be retained for a specified amount of time, records should also be destroyed on schedule.

Q

My department is very low on file space, and I need to throw away old files to make room for some new ones.
Can I throw away everything that is greater than three years old?

A

No. Your department or division has a formal retention schedule. Documents, records, and files must be retained as long as the retention schedule requires. You may arrange for storage of departmental files by contacting UTMB Records Management at (409) 747-5900.


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