Patient confidentiality
Posted By: Stephanie on 2009-03-01
In Reply to: What about EMR and confidentiality? sm - anonamiss
I remember when I first started out in MT in a hospital part of medical records confidentiality agreement was that we only had access to records on an as needed basis and were not to be talking to anyone about the things we transcribed even if it was a relative, family member, etc. That was gee now close to 10 years ago.
I know like others on the board, it would be nice to know what EMR will mean for all of us. If we are to be out of jobs, I would sure like to know now so that I can start planning financially. Also, as I have been searching for more information on implementation of EMRs, the more I get concerned myself about my personal information possibly being spread. Given my still rather young age of 31 and having no medical conditions requiring medical attention/medication, it really makes me wonder if I may want to look more into alternative medical care or a private physician who has alternative medicine in addition to medicine as we currently know it.
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IMO, you violated a patient's confidentiality by even posting about this - that you transcribed t
I know you didn't give any personal info, but even mentioning this in a public forum on the "world wide web" - I don't know, I would consider that a violation of medical record confidentiality. I know some may post a sentence or a blooper or something, but this is probably something I would have kept to myself... I am sure you thought what an interesting coincidence when you show the show, but my opinion is you should have kept it to yourself, and if I was the transcription supervisor at your hospital and I found out you had posted on this.... well I would think that would be reason for discipline. No offense meant, just my opinion.
What about EMR and confidentiality? sm
Have a bad neighbor who is a CNA (the worst-behaved person, drinks, yells, swears all day) and she now has access to medical records at a hospital. Someone was in the hospital anonymously but she proudly announced she "found" them and what was wrong with them, etc. How are we going to prevent people working in hospitals or nursing homes, etc., from accessing ours or our loved ones medical records? I see one heck of a mess here! My doc went EMR and now I am very careful what I say to him, some things I should tell him, I do not because I don't want it read by the whole neighborhood. What's your opinion on this?
Ever hear of confidentiality? nm
nm
PS to confidentiality breach
I should have said they "had" their confidentiality breached by others. The hospital was very apologetic of this and does not know who did it but called in federal investigators to find the source of the poster on the website.
security, confidentiality, etc...
I also have a home computer and all the same programs on a laptop to use when I travel. It's no different than my home computer. When I type at home, I am typing in my living room with my husband and son moving all around me. (We're remodeling right now.) They respect that what I am typing is no one's business and they have never even offered to look or ask what's going on. Furthermore, this is a family computer, not provided by work. They are on the computer quite alot when I'm not. The program in which I transcribe is password protected and the information on patients is not stored locally, but on a server 1000 miles from here. That's about as secure as you can get. Then, that is not to mention that I have a wireless network here at home, as well as when I travel. With a password and a good firewall, security is just not an issue. Also, see the post from Just Me a few down, about networks. She is correct. (I also have worked in IT for many years.) Hotels ARE secure networks with original passwords. The last one I worked in had to give me a new password daily. Working at McDonald's or an Internet Cafe is what wouldn't be safe.
As for the laptop... like I said for my main job, no patient information is stored on my hard drive, but at a server away from me. I have a local account also, and once I do the work and send it in, it is deleted. I personally don't see the concern. There's not any point when I'm traveling that I have patient data stored on the laptop. The only way anyone could get patient information off of it is if they bust in the door while I'm working and jerk it from me mid-note.
Confidentiality Agreement
Does anyone have a generic confidentiality agreement that they use for their clients. I have new doc, and I don't have any agreement in my file. I have signed theirs, but do not have one to offer the new doc. Anybody have one or know where I can find one? Thanks so much.
Confidentiality Agreement
There was an Agreement of Confidentialty that was posted on 05/20/09 by DeeAnn. that was really good. Hope this helps.
Putting patient versus The patient (sm)
When did this "rule" come about? I've been an MT/Editor/medeical records tech/ART for 30 years - Never, ever was I told to put that. You cannot make the sentence be "The patient sent to Radiology" but you can put "Patient sent to Radiology."
Thats just insane.
I have never signed a confidentiality notice that says
I can't mention what account I type on - I know they always say not to contact that place or try to get a job with them, etc., and I don't see the big deal either. I can't see why a company would care if someone knows what hospital you type for. I guess some places are just different, but seeing as how I assume she hasn't signed anything since she just accepted the job, I really don't see how they could not hire her because she mentioned that, not knowing that they didn't want her to. That's just my opinion though.
Hospital confidentiality breach in RI.
A hospital in Rhode Island breached patient information of over 2000. Federal investigation underway. Patient's names, SS#, telephone, etc., put out for all to see and caught by a patient who "googled" her own name. They say it was only face sheet info and hospital offered to pay for credit check or credit fraud alert. (Which is free by the way!) So please be careful who you get involved with. I don't believe it was medical transcription or medical records since it was face sheet information but believe me, all subcontractors to this hospital are now on alert and you should be as well. It's out there! The scum bags who post info are at it again. They also had a scandal at a RI supermarket chain where the credit card swiping machines were altered by crooks who are being charged with federal crimes, two would keep the cashiers busy while another would alter the card swiping machine, put it back to collect information, then come in again, take out the swiping info and people as far away as California were charging to these poor innocent people in RI whose cards were swiped while doing their weekly shopping. So don't think your information is safe anywhere. These stories can be confirmed by the local newspaper in RI, "The Providence Journal" at their website, "projo.com". Check it out!!
Absolutely Not. That is against HIPAA and will cause confidentiality breaches, nm
x
You should have signed a confidentiality agreement which allows you to type this unless-
you do not feel comfortable typing it, in which case I would ask my supe to reassign it.
The buck stops with you (all of us). What confidentiality means is
that you/me, the MT, do not discuss the name and contents of a report with anyone outside the immediate realm of responsibility and only within a professional context.
If you feel really uncomfortable with doing it and have the option of sending it back for someone else to do, that acceptable but not entirely necessary.
If you *have* to do a report on someone you know, do it, and put it out of your mind. If you see that person, you cannot discuss anything about it with them, even if they ask. The onus is upon us to keep.our.mouths.shut. That is all that confidentiality entails.
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when you work for a national, you sign a confidentiality agreement...?
the same rules would apply, and you must have signed a confidentiality agreement with whomever you work for. you can be fired, if breached.
my opinion, as a professional, you transcribe it and mums the word...
when I worked in a hospital, someone was caught 'sharing' information about the CEO from a transcription report, and was fired on the spot.
It's a written rule in some companies confidentiality agreement.
I know my company has it as a written rule so it just is not good business. I would think an MT would know this
Is the patient
x
patient name
It's surprising your company lets you put the name in the report. The trend has been to use "the patient" instead of the name.
The patient is...
The patient is a 2-month-old elephant.
The patient is a 2-month-old infant.
Work from India.
The patient will . . .
be maintained on a clear liquid diet. He is specifically instructed that beer does not constitute a clear liquid. (pt in for alcoholic gastritis) Still chuckle every time I think of that one!
Also that few MDs can say a patient is
slurring without stuttering or slurring the word, "slurring."
the patient
The client preference is to type "the pateint" To be even more exact, my account instructions state: "NEVER put patient's name in the body of the report, even if it is dictated. Always put 'the patient.'"
Usually if it's a no patient name
allowed either.
yea, but me as a patient...
when i asked to have copies of my medical records, i was APPALLED at the crap that was in them, by this I mean the errors ran rampant throughout, even if it was just a capitalization error, or incomplete sentences (which i consider errors).
I did not like what I saw at all, but would the average person care, if it doesn't change the meaning?
Patient logs
We are required to do a log for each batch of reports that we do. I will fill the info on the report and then control + end to the log and record the same info. Says time for me at the end of the whole document.
Patient info?
Where is my post on typing in patient information???????????
It took me 30 minutes to look-up a patient.
x
All FIVE of the patient's extremities....
Okey, dokey. This one's American, too.
Yes, and patient demographics.
I'm not going to compare myself to others, though. I've made a lot of progress, and that's all that counts. I've only been on this account for three months. Who's to say what I'll be able to do next year?
My doc would put that patient on protinix --nm
x
patient names
This is a problem that I am currently struggling with. My accounts are not 'searchable' and some docs don't spell out the patient's names. I have QC'd these many times with a note AND my e-mail address asking QC if I should be sending all these reports to them minus the patient's name, or send it to them GUESSING the spelling, or just spell the names phonetically and NOT QC them. About 15 requests now, and NO REPLY!! Very frustrating!!! Otherwise, the account is really good. I am new, so did not realize that other platforms gave credit for footers, headers, etc. I know on DQS you get a fair line count on just the body of the report. Don't know about the rest.
when I can't figure out the patient name (sm)
I just leave it blank because, like the other post said, I cannot get any feedback on what is protocol, so I make up my own. I aint gettin' paid enough to fool around trying to figure out what the dumb doc is saying!
Wow, I think I have PMS or something..I don't usually gripe this much! 
Patient Names
You'd be surprised how many facilities have the patient's name on the report. Its not that uncommon. Depends on the facility and the company you work for.
No patient transfered to the LSU
I'm in the procedure section where I cannot abbreviate...Help
RE No patient transfered to the LSU
ICU or CCU maybe - Intensive Care Unit, Coronary Care Unit, can't guess what LSU is in relationship to other than what was said above about football.
The patient is a male
The doctor said: "He denies bloody or cloudy urine, pain with urination and vaginal bleeding."
I crack up laughing and quote this to my husband, stating the patient's gender.
And his response was, "I hope so."
(think about it) 
This is actually between the doctor and patient.
Your job is to transcribe what the doctor wants. He's the one who needs to be compliant by having the paperwork in order to send these copies on. It's not your problem.
Probably something in patient care, maybe CNA. sm
They make about as much as I am making and with benefits on top of that at the hospitals around here.
Tks you all for being so patient. Looks like I'm out to buy WORD. I
computer and I don't see much, and nothing that says "autocorrect" or auto anything.
Yes, after being jerked around for several months now and starving to death I will feel better to get my feet on solid ground again with a local company that I know will be around and I know what the rules are (wink wink).
I'm off to find WORD. ((I don't know how people who have no time with computers at all, get geared up to work for MQ and do all this stuff with no help. I know a little bit/very little! and I just can't imagine just starting to work on a computer))
How old was your oldest patient? sm
Doesn't matter if it is someone you took care of or someone you typed a report about. I just did a report on a 103-year-old man and once while working as a aide, had a 104-year-old male patient. Cute as a button and sharp as a tack. Also had a 101-year-old lady at the nursing home. 
As MTs, our #1 priority is the patient, just
as it should be for doctors, nurses and health care professionals. I know how frustrating it can be trying to translate broken English, etc. I complain about it, too!! Sometimes I get so angry, because it actually takes money out of my pocket in that I spend so much time trying to "get it right" instead of just using my knowledge and typing skills typing dictation from a clear-speaking doctor with good English. Sometimes you want to just scream!!!  BUT, again, it is part of our job to provide an accurate and presentable medical document. I wish things were different, but it appears that we have to work with what we've got or learn a new profession.
That is my humble opinion. 
Pain Patient - Where are you??
I have been SO WORRIED about that lady last week who was withdrawining on her own from OxyContin and was gonna go alone to a hotel and float in their pool, supposedly with a load of VALIUM that was recommended to her on this board! Good Lord!! I just pray she is not dead. Seriously. I tried and tried to post, but was banned for some unknown reason. At any rate, if you are out there, please let us know you are OK. Also, PLEASE don't withdraw from these meds on your own - you can easily seize from opiate withdrawal - everyone is different, and no way should you take VALIUM. NO WAY. I am a huge pain management buff, being in the midst of it myself. Its not safe to do alone - I know - been there done that. The best thing to do is check yourself into one of the 3-day detox programs at any local hospital - no matter who your pain mgmt doctor is. I seriously doubt your doctor wants to keep you addicted, and if you called any authorities and reported that, he'd be in deep trouble. Narcotic scrips are one of the few heavily monitored items today. PLEASE DON'T TAKE VALIUM off scrip. There are outpatient meds like Suboxone - supposed to be a miracle pill. 1 or 2 pills a day, no withdrawal, no urges. Or you can get detoxed under anesthesia in a few hours. Or do the inpatient detox in 3 days with clonidine and possibly Ativan for anxiety. NO VALIUM. And they are set up for giving you the antiseizure meds immediately should you develop seizures, which is common. PLEASE tell me you are OK, and I have given you my email address if you want to write privately. I have been so worried about you. And I 100% totally understand.
PAIN PATIENT
www.pillsanonymous.com
Well, the patient does have some control, actually.
The patient can see another doctor without mentioning seeing this doctor, if he/she believes this MD's opinion is worthless. You can hope the best for the patient, but that's about it. Now if you worked in this MD's office as an employee or you were an IC (I am assuming you are doing hospital work and he is just one of the dictators), then you could decide you didn't want to earn your living from him anymore, but if you are in a service/hospital employee situation, then you just groan when you get him, call him ugly names if you work at home, type his reports, and steer your family and friends toward better MDs whenever possible.
I think most patients can recognize a jerk when they meet one.
The patient has never been pregnant
x
Sounds like she should be a patient there -
First of all, your supervisor(s)/lead(s) or whoever else is overseeing this dept. should be fired. Sounds like it's out of control - but if they are dumb enough to hire her - what do you expect???
If it is a quotation of the patient, I put it in ==sm
quotation marks. If it is not and just something the doc says, I try to change it without losing the context of the report. patient notes are no place for cuss words. I had a question about it one time and asked my supervisor. she said she wanted to know about it, so I flag it. I even had one doc cussing out the Transcriptionist during the dictation for misspelling a word on a prior document, which I thought was rude, because he has no idea which transcriptionist is getting his dictation. I told my supervisor about that too. He has not done it since.
We are not allowed to keep any patient sm
records on our computers, at all. They should be stored in the provider's files if they want to keep them for access.
The patient's status
I got one yesterday that the patient's status currently is deceased. Wonder if that status is going to change in the future.
Patient list.
I too get a faxed list. However, the physicians use the list first and mark the patients they have dictated on. Then I check off as I transcribe. They do not ask for the list back, but if I notice any that the physician has marked that I did not transcribe, I let them know. In my experience doctors usually swear that they dictated the note and tend to get upset if they have to redictate later. I have worked inhouse in medical records so I also know how frustrating it is when a note is missing. The tendency is usually to blame the Transcriptionist if a note is missing, so it is nice to have that list if something comes up. However, at this office a staff member there goes through and double checks to make sure that the dictation is there. It all makes for a good relationship with the client in my opinion.
Some places use the SS# as the patient ID #. (nm)
.
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