is this "allowed"?

[sassyann8585]

This is in regards to an electronic medical record. Say a patient comes into the specialty office where you work. Say they are requesting a vaccine and you want to see if they already got it. You pull up their vaccine record that pulls all of their immunization history for the health system, no matter where the vaccine was administered (ie-which particular Dr office within the system) and see the dates administered, but you are looking for details of this vaccine administration. You then look at their record and view the documentation for the office visit they had with their PCP, whose office you do not work at (but whose records, as I mentioned, are on the same electronic medical record system your office uses, all part of the same health system) in which they received said vaccine. Is this "allowed'? I am just super paranoid about HIPAA. But to me, if you are opening their record to find something related to the care you are providing them, it is not a violation, even if the documentation you look up was at another Dr's office than the one in which you work, but still under the same health system. Am I correct? OF course I could see a problem if you as the nurse went and pulled up documentation from another office totally unrelated to any care you were providing them.

[chrisrn24]

At my old job we had people signs waivers that we could view their immunization records.

Why if someone wants just their immunization are you looking at their other records??

[Meriwhen, ASN, BSN, MSN, RN]

This is a question that would be best answered by your facility's HIPAA compliance officer, IMO.

(also moved this thread to the HIPAA forum)

[sassyann8585]

the pt came in for gardasil and 4 vaccines were showing up in their immunization record, so I wanted to see if under the dates administered, on that date;s visit, if it was mentioned that they got the shot in the nursing documentation, or if the immunization was entered in error.

[michael.alicea]

For HIPAA, you can do anything which the patient authorizes, with a few exceptions and after getting reasonable assurances that you are dealing with the patient. Now the practice may have specific policies in place like requiring a written authorization. State medical records laws may also apply but they tend to favor patient access vs restricting it.

[Esme12, ASN, BSN, RN]

HIPAA is a need to know basis...if you needed to know the information then it is fine ....but I would check with the practice.

[nurseprnRN, BSN, RN]

This would very likely fall under the category of related information needed to give safe care, otherwise known as "in the normal course of business." I don't think you needed to make the extra step to check the actual office visit notes to verify the vaccination dates, especially if they contained information that had nothing to do with vaccination. You'd be entitled to trust the documentation that you saw indicating the vaccines had been given, but if you have an office policy to verify (not actually a bad idea to do that), then no problems in my opinion.