Health Information Compliance Alert

Question: I'm a desk nurse in hospital in a major metropolitan area. Given all this concern about privacy, I have a question: Is it actually a violation of a patient's privacy to tell visitors where the patient's room is located and/or what the patient's condition is?

New York Subscriber

Answer: No. Covered entities such as hospitals and other health care providers can use a facility directory to look up and relay patient information (including their location or general condition) to visitors.

Important: There are some rules governing what can be put in this facility directory. A patient's directory entry should contain only general information, including his/her name, location in the facility, a general description of the patient's condition (specific information about the patient's condition should not be included), and the patient's religious affiliation.

The facility may provide any of this information except for religious affiliation to anyone who asks for the patient by name. The Privacy Rule does permit covered entities to disclose the patient's religious affiliation to members of the clergy.

The patient needs to be informed about the directory, the information it contains, and the persons to whom directory information might be disclosed. The patient has the right to refuse his/her inclusion in the directory, or may restrict the information included or the persons to whom the information may be disclosed.

The patient may be informed about the directory verbally or in writing, and likewise has those two options for offering/withholding consent for directory inclusion.

If the patient is unable to offer consent to having their information disclosed, the covered entity is permitted to disclose directory information if the patient's care provider agrees that it is in the best interests of the patient.

Then, as soon as it is possible to do so, the provider is responsible for informing the patient about the directory and giving her options regarding the use of her personal information.