Administration Policies and Procedures

Confidentiality

Policy

In the course of performing work responsibilities, information is considered confidential with regard to patients, their families, their physicians and/or the facility. As a condition of employment, personnel are cautioned not to discuss any such information with others. Personnel shall not discuss patients in common areas or outside of the facility.

Medical records are accessed only by staff that is involved with the patient’s care. Medical records are protected from unauthorized access by storing in protected areas when outside of the secured medical records storage system.

The computer system requires access codes to obtain information from sensitive areas, i.e., business office, medical records.

Medical information, such as laboratory test results may only be accessed by facility staff that is involved with the patient’s care.

Patient physical assessments are conducted in a location that affords visual and auditory privacy.

Patient names shall not be used on lockers to protect the right to confidentiality and privacy.

Confidentiality of Patient Information

Policy

It is the policy of this facility to protect all patient’s rights of privacy. To assure that the patient’s rights of privacy are maintained, the following procedures will be implemented.

Procedure

Consent must be obtained from the patient to release information to third parties.

When receiving inquires regarding a patient’s condition by family members, friends and visitors, the following must be observed:

The individual requesting information must provide evidence of his or her identity, at which time if the patient is able to consent, written consent will be obtained from the patient and documented in the medical record.

The information verbally provided by personnel will consist only of brief description on the patient’s current condition in terms of “stable,” improving,” etc. The clinical health care provider must use their judgment in providing additional information and prudence is required.

If the patient is unable to provide written consent due to physical or mental incapacitation and there is an assigned surrogate decision maker for the patient, consent for release of verbal information will be obtained from the surrogate and documented in the medical record.

If the patient is unable to provide written consent due to physical or mental incapacitation and there is no assigned surrogate decision maker, verbal information as outlined in this policy may be provided to the following individuals:

• Spouse
• Adult children
• Children (as appropriate to age)
• Siblings
• Legal Next of Kin
• Caregiver/Guardian
  

Any other individuals requesting information regarding the patient must receive prior authorization.

As a condition of employment, all personnel are cautioned not to discuss any information regarding patients with others. Casual comments with fellow co-workers may be overheard and violate the trust others have placed in our personnel and facility.

As required by state and federal law, information pertaining to victims of abuse/violence/sexual assault will be released to regulatory agencies.

As appropriate to state and federal law, any patient information requested by state and/or federal agencies will be released accordingly.

Information related to insurance benefits that may relate clinically to the patient will be released only upon proper identification of the requesting individual and with consent of the patient.

Questions or Complaints

If you have questions and would like additional information you may contact the Civil Rights Coordinator/Privacy Officer at (406) 556-9000.

If you believe your rights have been violated, you can submit a written grievance describing the circumstances surrounding the violation to the Civil Rights Coordinator at Rocky Mountain Surgical Center 1450 Ellis Street Suite 101, Bozeman, MT, 59715 or to the US Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201 or visit their website for more information https://ocrportal.hhs.gov/ocr/portal/lobby.jsf.