Inpatient Facility Coding & Compliance Alert

Question: What guidelines should our behavioral health department 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 organization. The charts show the patient’s name and physician’s name; no testing or code indicators are visible. We felt that as long as there was no information other than the patient’s name, physician name and room number visible, we were doing it correctly.

Minnesota Subscriber

Answer: You’re definitely on the right track because you aren’t disclosing code or testing information. But there are even more steps you can take to ensure your patients’ privacy.

Best bet: Instead of using a patient’s full name, use her first initial and 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 specifically, to maintain patient privacy. 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 using the first initial, last name setup 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 organization 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.