General Surgery Coding Alert

Question: Are there specific guidelines that our surgical group should follow to protect the privacy of patient information in public areas? For example, we keep our charts in a rack visible to visitors who enter our office. Although the charts show the patient’s name and physician’s name; no testing or code indicators are visible.

South Carolina Subscriber

Answer: The chart situation you describe is a good start because you’re protecting diagnosis and testing information, but there’s much more you can and should do to ensure patient privacy.

Step 1: Explore the option of moving the chart rack to an area that is not visible to all the visitors entering your office.

Step 2: Consider not including the physician’s name on charts that could be visible to visitors.

Step 3: Instead of using a patient’s full name, use her first initial and last name (or first initial and only the first few letters of the patient’s last name). This works on several levels. First, it doesn’t pose a patient identity risk because it’s rare that there would be two patients with the same first initial and last name in the same room. This process also meets The Joint Commission’s Standard IM.2.10. Although The Joint Commission doesn’t specifically address patient privacy, your state and federal regulations do. And The Joint Commission does require organizations to be compliant with state and federal laws and regulations.

Another benefit to noting the patient’s name this way is that the patient’s gender remains undisclosed, which provides even greater security as a passer-by would know even less about the patient.

Trap: If your practice used first name and last initial, there would be a greater likelihood of having two people with the same first name and last initial in the same room. The same problem would occur if you used first initial and last initial.