SGCMH Release of patient Information
Privacy regulations issued by the Centers for Medicare & Medicaid Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) govern the use and release of a patient’s personal health information (PHI). In the event state law or hospital policy is more restrictive than the HIPAA privacy standards, the more restrictive law or policy will apply.
HIPAA privacy standards have specific provisions for the release of limited “directory” information without the patient’s consent or authorization. However, the patient must be told about the use of the information and must be given the opportunity to object to or restrict the use or release of the information. Unless a patient objects, the following information may be placed in a directory.
- the patient’s name
- the patient’s location in the health care provider’s facility
- the patient’s condition, described in general terms that do not communicate specific information about the individual
- the patient’s religious affiliation
Disclosure of this information for directory purposes may be made to members of the clergy or, except for religious affiliation, to other persons who ask for the individual by name.
HIPAA privacy standards regulations establish a minimum acceptable threshold for the use and release of PHI. State and federal law (see the following topic, “Confidential Information”), as well as hospital policies, may establish stricter standards. For example, hospitals are very cautious about releasing PHI about any patient associated with the commission of a crime or where the safety and security of both patients and hospital personnel may be jeopardized.
Patient Condition Reports and Information
Patient condition may be provided consistent with the limitations imposed by HIPAA privacy standards. If these standards are met, general condition information may be provided that does not communicate specific information about the individual. SGCMH uses the following one-word descriptions of a patient’s condition.
Undetermined — Patient awaiting physician assessment.
Good — Vital signs are stable and within normal limits. Patient is conscious and comfortable. Indicators are excellent.
Fair — Vital signs are stable and within normal limits. Patient is conscious but may be uncomfortable. Indicators are favorable.
Serious — Vital signs may be unstable and not within normal limits. Patient is acutely ill. Indicators are questionable.
Critical — Vital signs are unstable and not within normal limits. Patient may be unconscious. Indicators are unfavorable.
Treated and Released — received treatment but not admitted
Note: The term “stable” should not be used as a condition. Furthermore, this term should not be used in combination with other conditions, which, by definition, often indicate a patient is unstable. With written authorization from the patient, a more detailed statement regarding a patient’s condition and injuries or illness can be drafted and approved by the patient or legal representative.
When accidents occur, the media should call the hospital where the patient is transported for a condition report. Reports at the accident scene are not official condition reports. A condition report can be assigned to a patient only after a physician’s assessment.
Minor children (under the age of 18) may have information released with the consent of a parent or legal guardian, in accordance with the preceding guidelines. Minors under age 18 who are authorized to consent to specific medical procedures under state law retain control over the use and disclosure of PHI.