Medical records are kept confidential under the California statue “Confidentiality of Medical Information Act, Civil Code §56 et seq. This Act prohibits disclosure of medical information absent an authorization signed by the patient or the patient’s legal representative.
We make available to each employee certain information including patients’ names, medical history and addresses, communications, files, bills and payment records, office forms or manuals, etc. These items are of substantial value, highly confidential, and constitute the professional and trade secrets of the physician. They are confidential and provided and disclosed to the employees solely for use in connection with their employment.
Cardiology Medical Group maintains a policy of strict confidentiality regarding all patient care matters. Employees who handle confidential information are responsible for its security. Extreme care should be exercised to ensure employees safeguard confidential information to protect the patients, the practice, each staff member, the suppliers, and the employer. Any employee who violates this confidentiality and disclosure policy is subject to disciplinary action up to and including discharge, and in extreme cases, legal action. Personnel are required to follow these guidelines:
1. Provide patients access to their medical information.
2. Do not disclose medical information without the consent of the patient.
3. Allow adult patients who inspect their medical records pursuant to Health and Safety Code Section 123110 to provide a written addendum to the records if the patient believes the records are incomplete, inaccurate, out of date, or misleading. This addendum is limited to 250 words per incomplete or incorrect item and must be attached to the patient records and included when disclosed to other parties. Health care providers are not subjected to liability for the receipt and inclusion of these addenda in patient records (SB1903) per Health and Safety Code Section 123111.
•If a patient requests an amendment, the physician should add notes to the record to indicate the nature of the request and the changes made.
•If a patient requests access to their medical record, this information can be provided by way of a summary. Provision of a medical record or summary should always be accompanied by an explanation from the physician and an offer to discuss any patient concerns.
•On rare occasions, a physician can request that some information not be made available to a patient. This may be necessary if it is believed the information may be detrimental to a patient’s health and wellbeing if read by the patient.
•If requested by a patient, the clinic transfers a copy of the medical record or summary to another medical clinic or physician.
4. Ensure authorization forms permitting release of medical records specify to whom the information may be released, the type of information being requested, and include the date and signature of the patient or representative. The patient’s name, medical record number, name and organization of the requester, date of request, and the date the record was released is documented and filed in the patient’s medical record.
5. Do not disclose any psychotherapy outpatient treatment without written consent by the patient, and notify the patient of the request.
6. Give patients the opportunity to consent to or deny the release of medical information, except as required by law.
7. Physicians can disclose patient medical records without patient authorization when authorized by law.
8. Disclose medical information as required to secure payment to insurers, employers, health plans, government entities, or others responsible for payment for services.
9. Physicians can request a reasonable reimbursement for the cost of copying a patient’s medical records.
10. Regard and preserve practice information as highly confidential and trade secrets of the employer. Do not disclose or permit to be disclosed any of this information to any person or entity. This includes the following:
•Do not discuss this information away from the premises or within hearing distance of any patient or unauthorized person.
•Do not photocopy or duplicate, and do not permit any person to photocopy or duplicate, any practice information without the employer’s consent and approval.
•Continue to keep any information inviolate, even after termination of employment with the office.
•Only release personal information, such as telephone number, address, etc., about other staff members with the staff member’s specific and prior approval in writing.