HIPAAPatient Directory

Policy 3.1.20 in the Administrative Guide

Created by CCTC

Patient Directory Information we can sharewith the public but is limited to: The patient’s name Location in our facility One word statement of condition, such as

good, fair, serious, critical. (released by patient care team)

Religious affiliation (available only to clergy)

Patient can exclude some or all of their information from the directory.

Created by CCTC

Who Can Information be Shared With?

Unless the patient asks us not to, this information can be shared with:

The clergy. For example, the Methodist pastor can obtain a list of Methodist patients.

Others who ask for the patient by name. For example, patient visitors and florists.

Created by CCTC

Outpatient Clinic Workflow1. The following statement about the directory

will be included with appointment reminders and other printed materials provided to the patient as appropriate: Patient Directory- UAMS maintains a list in the computer system of current patients and their scheduled clinic. This information may be provided to callers and/or visitors who may need to locate you. If you do not want to be in this directory, please call the clinic. Similar information may also be included in area signage.

Created by CCTC

Outpatient Clinic Workflow

2. The patient will be included in the directory unless they tell us not to include them. The directory is visit specific so a request will need to be made for each visit. For outpatient clinic purposes, directory information is limited to patient name and location.

Created by CCTC

Outpatient Clinic Workflow3. Patients who are present and wish to be

omitted from the directory will fill out a Request to be Excluded from the Patient Directory form that will be scanned into EPF in the “HIPAA” document type. If the patient is not present, the registration person taking the information will fill out the form. The staff will need to clearly outline for the patient the consequences of this request, i.e. that we will not be able to provide their clinic to family and friends trying to locate them.

Created by CCTC

Outpatient Clinic Workflow4. Documentation will be maintained in OSCAR

in the “Info Release Indicator” field in PATU regarding the patient’s directory status. The “Info Release Indicator field” is usually empty. It should only have something entered if the patient has asked to be excluded from the directory. In that case, the registration person will add the ‘N” (no info) flag in the “Info Release Indicator” field in OSCAR to indicate that “no information” is to be given out on the patient. The ‘N” flag will prevent the patient from displaying on the Patient Information Screen.

Created by CCTC

Patients will be included in the directory unless they tell us not to include them.

Patients who “opt out” of the patient directory will have an “N” enter in the “Info Release ind” fields PATU.

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BALL, LUCILLE 001060015-1262

Created by CCTC

What Do I Do When Asked for Patient

Directory Information? 5. When a visitor asks for a patient location, you

must use the Patient Information Screen in OSCAR to assist them. Only today’s visit will display. If the patient is listed, you may provide their location if it displays. If the patient is not listed, they may have asked to be excluded from the directory, or they may not be a patient here. Tell the requestor, “I’m sorry, I don’t show them in our system. They may not be a patient here or may have chosen to not be listed in our directory.”

Created by CCTC

The OSCAR Patient Information Screen only displays outpatients. You can call the Patient Information Desk at 686-6416 and obtain information to assist the visitor if the patient is an inpatient. When questions arise, be sure and request assistance from your supervisor. Note: it is not necessary to check the patient directory before providing directions to visitors who ask where a specific clinic or doctor’s office is.

What Do I Do When Asked for Patient

Directory Information?

Created by CCTC

To assist a visitor go to “Patient Information” only

Created by CCTC

Look up patient

BALL

Created by CCTC

If they display, you may provide their location

BALL, ABBIEA/FCM

BALL, LUCILLE A/NEUM

BELL, DING A/FCM

BELL, DONGA/EYEB

CHICK, HENRY A/NSUR

CHILDREN, KK A/EYEB

COLEMAN, MILK A/NEUM

COOL, DUKEA/MED

BALL

Created by CCTC

Inpatient Workflow

Created by CCTC

Patients will be offered the opportunity to “opt out” of the patient directory at registration.

The patient will be included in the directory unless they tell us not to include them. The directory is visit specific so a request will need to be made for each admission.

BALL, LUCILLE 001060015-1262

Created by CCTC

Registration Staff will select the appropriate flag in the “Info Release Indicator” field when registering a patient who has “opted out” of the directory.

N - No Info ( to be used if the patient “opts out of the entire directory – no name, no location, no condition, no religious preference)

L - No Loc (to be used if the patient wants only their location omitted from the directory) C -No Condition (to be used if the patient does not want their condition released) D -No Loc/Cond ( to be used if the patient does not want their condition or location released)

Created by CCTC

Additional Information

Patients who request their religion to be omitted will have their denomination entered as “none”.

Admissions will stamp the patient information sheet to indicate when a patient has been admitted to the hospital and requested to have any or all of their information omitted from the directory, and they will call the unit.

Created by CCTC

Provisions of Inpatient Information from the Patient Directory

What do I do when asked for Inpatient Directory Information?

Refer clergy requests to the Office of Pastoral Care.

Refer requests from the media to the UAMS Office of Communications and Marketing, (501) 686-8149 or (501) 395-5989 in accordance with Policy A.2.01 – Media Relations and Release of Information. After hours calls will be referred to the Assistant Director of Nursing via the Hospital Operator (501) 686-7000.

Created by CCTC

All Other Requests

All other requests for patient directory information must be provided via the HBO INFO (Information Desk Inquiry) screen or by calling Patient Information at 686-6416. Note: the HBO INFO screen can be utilized to locate both inpatient and outpatients.

If the patient displays on the INFO (Information Desk Inquiry) screen, you may provide their location if it displays and refer requests for condition to the nursing unit.

If the patient is not listed, they may have asked to be excluded from the directory, or they may not be a patient here. Tell the requestor, “I’m sorry, I don’t show them in our system.”

When questions arise, assistance from a supervisor should be sought.

Created by CCTC To assist a visitor go to “INFO” only

Created by CCTC

Look up patient

BALL

Created by CCTC If they display, you may provide their location

BALL, ABBIE

BALL, LUCILLEBELL, DING BELL, DONG CHICK, HENRY CHILDREN, KK COLEMAN, MILK COOL, DUKE

BALL, SEX: F

If I am a patient at this facility, I understand that the following information in the facility’s Patient Directory is available to any person who asks for me by name:

(1) my name; (2) my location in the hospital or clinic location; and (3) a one word statement of my general medical condition (such as good, fair, serious, critical), without any other specific medical information.

I also understand that members of the clergy may receive this information, along with my religious affiliation, even if they do not ask for me by name. PLEASE COMPLETE ONE OF THE FOLLOWING IF YOU WISH TO RESTRICT THE RELEASE OF INFORMATION ABOUT YOU FROM THE PATIENT DIRECTORY [ ] I do not wish to be included in the Patient Directory. I understand that my exclusion from the Patient Directory will keep this facility from releasing my room number or clinic location to florists, friends, and family and from transferring phone calls to my room.

OR [ ] I agree that my name can be listed in the Patient Directory, but I want to restrict the release of the following information from the Patient Directory: (check all that apply)

[ ] Do not provide my room number or clinic location [ ] Do not provide a one word statement of condition (such as fair, serious, critical) [ ] Do not provide my religious affiliation

I understand that the above restrictions will apply only to this visit or admission, and that I must request restrictions again at future visits if I want any restrictions to be in effect. ___________________________ _______________________________ _________________________ Date of admission or clinic visit Signature of patient or representative Today’s date [ ] Verbal request and the patient or representative was not available to fill out this form.

FOR STAFF USE ONLY [ ] If a request to exclude information from the Patient Directory is initiated by UAMS, instead of by the patient or a patient’s representative, check this box and sign/date below. _____________________________________ _________________ UAMS employee making the request Date [ ] Patient or UAMS request received and documented in HBO/OSCAR. _______________________________ _________________ UAMS Signature Date

Request to be Excluded from the Patient Directory

Patient Label if available or

Print Patient Name

Patient Account Number S

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