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Discussion

Hippa and nurse notes

I have a question as to if this situation is a Hippa violation or not? As a phone nurse you take a phone call from a company that your office submitted paperwork to, to try and get a product covered. The company calls the phone nurse and explains to her that they received the paperwork with the incorrect pt's info. Is it a violation to type a nurse note in the pts chart that states the cob=nversation including the wrong pts name? Thanks

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Honestly, it is best to understand your own employer's policies for handling and documenting this.

1. They may (should) have an incident reporting process. Incident reports are not mentioned in any patient's record.

2. There is no reason to mention the other patient's name, even if the company policy involves noting this phone call in the original patient's medical record. And yes, doing so (including the second patient's name) would technically be a HIPAA violation as far as I know.

3. Why do you need to write anything in any record? An incident report may cover it. Ask your employer.

Let's say I receive a call from this company and they say they received incorrect information. If I have to document this because I have to document all calls according to company policy, I would document in the original patient's record: "Received phone call from ABC Company with request for patient information regarding coverage of _____. Information sent according to policy." There is no need to elaborate; you don't need to write, "we sent the information two days ago but really it was the wrong patient's information so now they are asking us to send the correct patient's information..."

4. The fact that the wrong patient's information was sent is an erroneous disclosure of PHI. Your employer should be notified of this.

HTH

I wouldn't write a note in John Smith's chart to say "insurance company called and said that they received a prior authorization under the name Joseph Smith" or anything of the sort if that's what you're asking. I would file an incident report noting that Joseph Smith's PHI had been inadvertently sent to Insurance Company X and resubmit the paperwork with the correct patient information. Perhaps make a note in John Smith's chart that request for PA was re-faxed to Insurance Company X on 9/24/17.

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