Confidentiality, Privacy and Security

Redacting patient records

  • 1.  Redacting patient records

    Posted 07-03-2019 16:11
    Hello All,

    For reference, I live in Massachusetts where state law explicitly prohibits the release of records where HIV, drug abuse, etc without written patient authorization. In a situation where a patient has allowed for the release of drug abuse records but not HIV information, would you redact HIV information from the record and then release the information? Or, as I feel, not send the record at all. Wouldn't redacting the record be tampering with the integrity of the record? Any experience with this appreciated!

    Thank you

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    Robert Gorman
    Coding Specialist
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  • 2.  RE: Redacting patient records

    Posted 07-04-2019 00:30
    Hi Robert,

    I also live in Massachusetts and have come across this situation countless times. You are perfectly okay redacting any statutorily protected information that a patient does not specifically consent to release. In your situation I would have redacted anything within the record regarding HIV treatment and then sent the record.

    I understand your hesitancy but you aren't changing the original legal medical record, just a copy for continued care purposes in accordance with the law. The most important thing is explaining to the requesting facility the patient they're treating has statutorily protected information within the records they're requesting. It can be difficult when patient care is top priority, especially when the record requests are urgent. At our facility we had to develop a policy allowing HIM to release statutorily protected records when a patient is unable to sign a form due to being incapacitated (which is allowable).

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    Kenneth Starkey
    Supervisor, Document Management
    UMass Memorial Healthcare
    Kenneth.Starkey1@umassmemorial.org
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  • 3.  RE: Redacting patient records

    Posted 07-05-2019 10:51
    ​Hi,
    Would you mind sharing your policy/guidelines on redacting?  I would certainly appreciate it.
    Thank you,
    Lynn

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    Kathryn Boyes
    Director, HIM
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  • 4.  RE: Redacting patient records

    Posted 07-05-2019 16:53
      |   view attached
    Here is our Release of Information department's procedure regarding redacting records for release purposes. I removed some information per our organizations policy on sharing a policy or procedure.

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    Kenneth Starkey
    Supervisor, Document Management
    UMass Memorial Healthcare
    Kenneth.Starkey1@umassmemorial.org
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    Attachment(s)



  • 5.  RE: Redacting patient records

    Posted 07-06-2019 15:32
    ​This is a very interesting and informative discussion, and  a  challenging issue related to continuity of care and patient safety. I understand I am stating the obvious, by not releasing important information regarding a very significant health care issue, through redaction  or not releasing without authorization, may affect the patient's health in a negative way as the provider may not be aware of this condition when making treatment decisions.



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    Dana DeMasters, MN, RN, CHPS
    Privacy/Security Officer
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  • 6.  RE: Redacting patient records

    Posted 07-06-2019 21:02
    Edited by Robert Gorman 07-19-2019 15:24
    Hey Dana,

    I was struggling with a similar issue. I considered two things. One, if the patient says we cannot release sensitive PHI as defined by MA law, are we obligated to release that record if they explicitly said we cannot ? Secondly, is it medical record's responsibility to redact this information? If the patient has information they are not willing to release, then by law we must comply with their request. It would be confusing if we were to alter the integrity of the record  being released by redacting. If the note includes more than one category of sensitive PHI,it is tricky but there is no legal obligation for medical records departments to redact records. This is perhaps the most frustrating grey area between federal and state law regarding ROI when considering HIPAA regulations and state law.

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    Robert Gorman
    Coding Specialist
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