Keep client and agency info in the right hands
Keep client and agency info in the right hands
Wandering eyes, loose lips are primary concerns
President Clinton and Department of Health and Human Services Secretary Donna Shalala may be focusing on electronic medical records in their concerns over patient confidentiality. But privacy of electronic information is only one piece of the puzzle. Home health agencies also need to be sure they have set policies that protect paper files and keep staff’s lips zipped.
"Agencies should have a policy and a culture consistent with that policy that says you don’t receive information, even internally, unless you have the need to know it," says Elizabeth E. Hogue, JD, a health care attorney specializing in home care in Burtonsville, MD. Once an agency decides who should have access to information, other people, including staff, should not have access to it.
"That ought to be the standard," she says. "People who don’t abide by that policy and that culture ought to be counseled and disciplined." (For a Joint Commission on Accreditation of Healthcare Organizations standard on medical records confidentiality, see p. 124.)
Agencies need to protect the privacy of patient information to decrease their risk of liability and to meet state licensure requirements. Providers recommend establishing an agency’s confidentiality policy quickly and firmly with staff. Angelo Healthcare Services, a private duty agency in San Angelo, TX, tackles the subject in staff orientation.
"Our employees are told that all services are provided in total and absolute confidence," says Diane Ross, RN, director. "We feel it’s important to go over that with unlicensed personnel because they haven’t had the training that the professionals have."
Angelo Healthcare has a handout that explains how to handle documentation. The sheet includes a paragraph that defines confidentiality and emphasizes that staff are not to discuss the case with anyone even family members. "They are not to discuss their clients’ names, where they are working, or give out client phone numbers to family members. If their families need to get in touch with them, the family should call the office, and we can take it from there." (To see how an agency handles the special confidentiality challenges of a small community, see p. 125.)
Several areas in home care lend themselves to breaks in confidentiality. Here are some problem areas and tips from Hogue and several providers on how to fix them.
- Problem area home folders.
As a common practice, some agencies leave folders with client information in the client’s home. Hogue says she has mixed feelings about these folders.
"In some ways, it’s a good device for various people on shifts to communicate with one another," she says. "Some agencies use it as a device to communicate with families, too. The families can make notes in the [folder] about things that concern them or things that happen while the caregiver isn’t there."
On the downside, leaving patient folders in the home can endanger the confidentiality of the information or result in the agency losing control of the record altogether.
For example, suspicious family members might comb through the folder for things to complain to the agency about, Hogue says. Family members may also become proprietary of the information.
"I’ve seen situations in which the families decided that the [folder] belonged to them because it was maintained at home," she says. "When services were terminated or the person died and the agency tried to retrieve the folder, the family refused to let the agency have it."
Staff also may be reluctant to write information in the folder that’s negative or could be interpreted by the family as derogatory. "Leaving it at home compromises the usefulness of it in some ways."
As an alternative to leaving client records in the home, Hogue suggests having more case conferences, both with staff who handle the case and with family members. "That way you get the dialogue without the complicating factors."
Angelo Healthcare requires its aides to keep the folders with them to ensure the confidentiality of the information. "If we have a homemaker or nurse aide going in once or twice a week, we ask them to take their notes in and bring them out not to leave the notes in the home," explains Ross. "If we have around-the-clock care, the folder stays in the home and goes from person to person and shift to shift. That way the records are always with an employee."
Clients or families wanting to keep the notes hasn’t been a problem, she says. "Before we even start the case, we explain to [the clients and families] that we will have notes and that they are our property. We need them for legal purposes."
- Problem area duplicate patient information.
Sometimes agencies make copies of patient documentation; how do you properly dispose of the information when it is no longer needed? "Be sure to take patient information that is no longer needed back to the office," Hogue says. "You never know who’s going to see what."
And don’t just crumple up the record and throw it in the office trash can. "At least make sure it’s torn up first," Hogue says.
"We shred everything, says Mary Skowbo, RN, director of home health, Shannon Home Health Services, a hospital-based agency in San Angelo, TX.
"We shred anything on paper that is not necessary and has a patient’s name and information in it," says Paula Salhany, RN, FNP, director of home care services at Baptist Community Home Care in Centerville, TN. "We used to burn it but that was too much to keep up with. It takes less time to shred."
- Problem area telephones and cellular phones.
Almost anyone who has a cellular phone has unwillingly picked up on another caller’s conversation. Staff who use cellular phones, therefore, need to be extra careful what they say over the airwaves. "We had to define what staff were going to share on cell phones. If it’s sensitive material, we recommend they make the call to the office from a private phone," Salhany says.
Even if it’s not sensitive material, Salhany recommends that staff use a medical record number to refer to a patient. "If they can’t remember that number, then they can use an initial."
Staff also need to watch what they say when talking on the telephone in the patient’s home. "When we page our staff in a patient’s home, we tell them to call us back and say, I got the page.’" says Skowbo. "[We tell them], Don’t start talking about other patients in that patient’s home.’"
Once leaving the patient’s home, staff can call the office on a secure telephone and talk in depth about the other patients.
- Problem area fax machines.
The fax machine is a bridge between word-of-mouth communication and electronic data transmission. It’s also a necessity in today’s world, says Hogue. "I have heard some attorneys say [faxing confidential information] is not allowed, but I don’t know how you could not fax."
The key is to be sensible about faxing information. "If something is particularly sensitive and you know it, take special precautions in the form of calling someone at the other end and asking him or her to stand by the fax machine to receive the document."
Also protect yourself if someone calls and asks you to fax information. "Get a written request and the appropriate authorization [from the patient] first."
Most of the providers call to make sure the fax was received on the other end. Salhany also keeps the fax machine in a somewhat secluded area.
"That way anyone wandering down the hall housekeeping staff or family members of employees won’t come across it."
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