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Discussion

Dictating notes to be transcribed....HIPAA Violation?

Friend of mine is a home health RN. She sees 30 patients a day on average and to save some time dictates her notes to be transcribed for a portion of her patients. For some of her patients she actually writes her nursing notes by hand in the charts and the others she dictates the notes and has a person she pays to write the notes out and stick them in the charts.

She asked me if I thought it was a Hipaa violation to have somebody who is not a RN transcribe notes for her. As a FNP I thought that was a great question but I didn't have a great answer. I know MDs dictate notes all the time and have them transcribed by transcriptionists whether they are local or overseas in India. What is your opinion of the practice? I'm not asking for legal advice, just your opinion.

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    It's not.

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    A transcriptionist is just part of the medical team. They are used all the time :)

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    Just make sure your contract covers all the HIPPA stuff. Confidentiality and protection of the PHI.

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    Not a violation, but the transcriptionist should be asked to sign a confidentiality statement that is kept on file, just as any employee would do if he/she has access to medical records.

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