OPO
TITLE:
DEPARTMENT:
SECTION:
POLICY:
REVISION:
EFFECTIVE DATE:
PATIENT CONFIDENTIALITY
PURPOSE:
The nature of O P O ’ s N a m e business requires all personnel to handle
confidential information regarding donors and/or recipients on a daily
basis. This policy establishes what O P O believes about the handling of
such information both internally and with regard to external sources and
environments.
POLICY AND STANDARD OF PRACTICE:
This policy encompasses all donor and recipient information either
communicated or transmitted electronically (i.e. email or fax) or retained
in written, electronic, or hard copy form. It applies to all staff, and
intends to protect the ethical and legal rights of all medical patients
involved with donation or transplantation in this state, and in any other
OPO or transplant program with which O P O does business.
O P O N a m e complies with all applicable statutes that impose obligations
on an OPO to maintain the confidentiality of medical records of donors and
recipients.
Although O P O is exempt from complying with HIPAA regulations, many of the
vendors and partners we interact with are not HIPAA exempt. All patient
info is maintained, and treated with extreme caution, sensitivity and confi d e n t i a l i t y .
O PO shares donor information with outside agencies that partner with O P O
for the purpose of facilitating organ and/or tissue donation and
transplantation. These agencies may include organ transplant centers, organ
procurement organizations agencies and research agencies.
OPO shares the
minimum information necessary and uses discretion when transmitting i t s
information.
-v , "
O P O shares some recipient demographic information with donor families as a
part of the standard donor family follow up. However, this information is
indicate the identity of_!h ecipie=!'J:. The
sameis true of donor informat on occasionally provide2lto recipients.
This confidentiality between IOPO and donor families, and IOPO and
recipient families is_NEVER viol.ated. However, in the event that mutual
' written consent is provided by both recipient and donor family for ongoing
communications between the two, O P O will assist with facilitation of
such requests: Even given such consent, it is often possible for OPO to
facilitate such ongoing communications without identifying either party by
name. When this can be done, it is.
Any identity disclosure that does
Policy QS A5.000
PAGE
2
OF
5
occur must be done according to IOPO Policy FS C3.000 Donor
Family/Transplant Recipient Communication and Identity Disclosure.
Occasionally, due to circumstances beyond the control
reveal the identity of a donor or recipient(s). O P O
in any external discussions or communications of this
available that the donor next-of-kin and/or recipient
to such discussions/communications.
of OPO , the media may
will not participate
kind, unless proof is
patient(s) have agreed
It is the responsibility of all employees of OPO to maintain and protect
the confidentiality of donor and/or recipient medical information and
identity. The following are guidelines O P O has put in place to ensure
that patient information is maintained and shared in the most confidential
manner possible:
1.
2.
3.
4.
5.
6.
7.
8.
Policy
OPO employees will refrain from engaging in discussions involving
organ and/or tissue donor cases or any patient information in an
unsecured area where those discussions may be overheard by non-OPO
employees. This includes public areas, hospitals, etc.
The medical records rooms are equipped with key fob entry. Key fob
access to the medical records room will be granted only to OPO
employees who have a business need to access the medical records
room. The medical records room will remain locked at all times.
OPO donor charts are not allowed to leave the medical records room
unless prior approval is granted by the Director, Quality and
Regulatory Affairs. If approval is granted, donor charts and other
patient identifying records, in addition to referral forms, will not
be left unsecured and/or unattended at any employee's desk or other
work space. All donor information must be put away in a locked area
or returned to the medical records room if the employee needs to
leave their workspace for any reason.
Copying any portion of the donor chart and maintaining it for future
use to carryout ones job function is strictly prohibited. Employees
should consult the original paperwork in the donor chart instead of
maintaining copies in their workspace or possession.
Donor information shall not be left unattended on printers. If
information containing patient identifying information is sent to a
printer, it must be obtained immediately. If any IOPO employee finds
such information on or around a printer, the information should be
shredded.
Minimal patient information is disclosed when leaving company or
department wide daily voice mail reports, such as case completion
reports. Patient initials are used instead of patient names, and
demographic information, such as age and race, should be kept to a
minimum.
Donor numbers or initials are used in place of donor names whenever
possible.
This applies to any email messages that are sent either
internally or externally as well as the use of portable laboratory
analyzers on organ donor cases.
All faxes, incoming and outgoing, that contain confidential patient
information are to be sent or received via the medical records room
fax machine when possible. If it is not possible to utilize the fax
machine in the medical records room, the utmost caution should be
QS AS.OOO
PAGE
3 OF 5
9.
10.
11.
12.
utilized to ensure that the correct individuals have received the
information and that patient information is not left unattended on an
unsecured fax machine.
Any paperwork containing confidential patient information that is to
be discarded will be shredded.
Billing requests requiring confidential patient information will be
considered on a case by case basis, and must be approved by the
appropriate Manager and/or Director.
At all times, OPO employees will treat patient information with the
utmost confidentiality.
The sharing of patient information
electronically (via fax or email) is extremely sensitive and should
be treated with caution as it may be possible for that information to
be accessed by outside individuals. Likewise, patient information
maintained via hardcopy will also be treated confidentially and with
sensitivity at all times.
If there is ever any question as to whether or not it is appropriate
to share patient information with an external source, OPO employees
should seek the advice of their Manager and/or Director or the
Director, Quality and Regulatory Affairs.
The Director, Quality & Regulatory Affairs, in conjunction with the
Leadership Team, is accountable for ensuring that confidentiality is
maintained at all times.
REFERENCES:
DEPARTMENTS EFFECTED:
SIGNATURE
Policy
QS AS.OOO
DATE
PAGE
4 OF 5
APPROVED MANAGER,
INFORMATION SYSTEMS
APPROVED MANAGER, TISSUE SERVICES
APPROVED MANAGER,
VITAL LINK DONATION
CENTER
APPROVED DIRECTOR, ADMINISTRATION
APPROVED DIRECTOR, FAMILY SERVICES
APPROVED DIRECTOR,
FINANCE & Is
APPROVED DIRECTOR, FUND DEVELOPMENT
APPROVED DIRECTOR, ORGAN SERVICES
APPROVED DIRECTOR, PROFESSIONAL
SERVICES & PUBLIC AFFAIRS
APPROVED DIRECTOR, QUALITY &
REGULATORY AFFAIRS
APPROVED DIRECTOR, TISSUE SERVICES
APPROVED CEO
Policy QS A5.000
PAGE 5 OF 5
POLICY & PROCEDURE REVISION HISTORY
Policy
Number
QS A5.000
Revision
Number
00
Effective Date
08/01/2005
Policy created. Content of OPO policy ADM 10.000 "Release of
Donor/Recipient Information" moved to this policy. Added statement
on HIPAA Regulations. Added more detailed information on OPO's
guidelines to protect confidential patient information.
01
07/01/2006
Referenced Ft. Wayne medical record room
02
08/15/2007
Updated signature section to reflect current leadership team and
minor grammical changes.
03
11/01/2008
Updated titles and signature section to reflect current leadership
team.
04
10/15/2009
Removed reference to key code access to medical records rooms.
Referenced that donor charts are not allowed to leave medical
records room unless granted approval to do so. Added the statement
prohibiting copies of donor charts being maintained at employees
workspace or in their possession. Updated management titles and
signature page. Revised OPO logo.
05
12/18/2010
Added OPO Foundation as department effected. Revised signature
page.
Policy QS A5.000
Title:
Patient Confidentiality
Description of Change
PAGE
1 OF 5